A federal district judge in Texas on Friday singlehandedly tried to put an end to the Affordable Care Act, ruling that the entire law is unconstitutional because the Congressional tax bill passed last December eliminated the penalty for not having health insurance. Although the case will be appealed and will likely appear before the Supreme Court, the judge’s decision has led to uncertainty for almost every American as the ACA touches nearly all aspects of health care. Kevin Mowll, executive director of RISE, offers his thoughts on the latest legal twists and turns and what’s next for the ACA.

U.S. District Judge Reed O’Connor released his decision on Friday, just hours before the deadline for Americans to enroll in ACA plans in states that use the federal insurance exchange.

In his 55-page ruling, he sided with a group of 20 Republican state attorneys general and governors, who claimed the law became unconstitutional when Congress enacted President Donald Trump’s tax overhaul and eliminated the tax penalty as part of the law’s individual mandate that required most Americans to buy health insurance.

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Congress stated many times unequivocally—through enacted text signed by the President—that the Individual Mandate is 'essential' to the ACA. And this essentiality, the ACA’s text makes clear, means the mandate must work 'together with the other provisions' for the Act to function as intended,” O’Connor wrote in the ruling.

However, because O’Connor issued a declaratory judgment and not an injunction, the law remains in effect throughout the country while the decision is appealed and likely makes it way to the Supreme Court.

Indeed, in a tweet on Friday, Seema Verma, administrator for the Centers for Medicare & Medicaid (CMS), indicated she expected the decision would be appealed and said that while the federal court decision moves through the courts, there is no impact to current coverage or coverage in 2019 plans.

A coalition of 18 Democratic attorneys general who defended the health law in the case vowed to fight O’Connor’s decision.

“Today’s ruling is an assault on 133 million Americans with preexisting conditions, on the 20 million Americans who rely on the ACA for healthcare, and on America’s faithful progress toward affordable healthcare for all Americans,” California Attorney General Xavier Becerra, who argued on behalf of the coalition that the mandate remains constitutional, said in a statement. “The ACA has already survived more than 70 unsuccessful repeal attempts and withstood scrutiny in the Supreme Court. Today’s misguided ruling will not deter us: Our coalition will continue to fight in court for the health and wellbeing of all Americans.”      

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Kevin Mowll, executive director of RISE, said it’s hard to imagine that the Supreme Court would rule that the entire ACA legislative package would be inseverable, particularly given the enormous scope of the regulations.

The ACA not only provides health insurance to millions of Americans, it implemented major provisions for changes to the Medicare Advantage (MA) program, said Mowll, who will moderate a roundtable discussion on health care’s evolving landscape at RISE Nashville in March.

Those changes included the reduction of the payment rates to MA plans over time, the introduction of value-based bonus payments for the Stars program for MA plans, preventive health benefits for all Medicare beneficiaries, and the gradual closing of the Part D prescription drug “donut hole.”  Other industry experts note that the ACA also expanded the Medicaid program and the structure of the Indian Health Service.

“If the logic of inseverability holds, then all of this goes out the window as well,” Mowll said. “The end result of this recent ruling, however, is that the politics of the day continue to churn along, while the business of providing health coverage for those enrolled in the Department of Health & Human Services plans must continue and their health care remains uninterrupted despite the ever-present threats and obstacles thrown their way."