WASHINGTON — The decision by a federal judge in Texas to strike down all of the Affordable Care Act has thrust the volatile debate over health care onto center stage in a newly divided capital, imperiling the insurance coverage of millions of Americans while delivering a possible policy opening to Democrats.
After campaigning vigorously on a pledge to protect patients with preexisting medical conditions — a promise that helped return them to the House majority they had lost in 2010 — Democrats vowed to move swiftly to defend the law and to safeguard its protections.
On the defensive, Republicans campaigning this fall promised that they, too, backed the health law’s protections for people with preexisting medical conditions. But the Texas ruling illustrated the fruits — and possible perils — of their long-running campaign, stepped up in the Trump era, to remake the judiciary through the confirmation of dozens of conservative judges, including two appointees to the Supreme Court.
The ruling, if it stands, would not only do away with coverage protections for people with preexisting health conditions but also strike down the guarantee of coverage for what the law deems “essential health benefits.” These include emergency services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs, and pediatric care.
But it is so sweeping that many legal analysts believe it is likely to be overturned. The Supreme Court, in a 5-4 decision, has already upheld the Affordable Care Act’s legality. The political reaction to the Texas decision, though, is not likely to diminish anytime soon.
“This is a five-alarm fire,” said Senator Chris Murphy, Democrat of Connecticut. “Republicans just blew up our health care system.”
Republicans were by and large muted in their response, but incoming House minority leader Kevin McCarthy of California appealed to Democrats to come to negotiate a successor to what he called “an unconstitutional law.”
“President Trump has made clear he wants a solution, and I am committed to working with my colleagues on both sides of the aisle to make sure America’s health care system works for all Americans,” he said in a statement Saturday.
The Democrats’ first step will be in the courts; aides to current House minority leader Nancy Pelosi of California said Saturday that House Democrats would move quickly to notify the Trump administration that they intend to intervene in the case. A vote on a resolution to do so is expected in the earliest days of the new Congress.
Democrats also intend to convene hearings to spotlight the sweeping impact of the Texas ruling — and lay the groundwork for their case to reclaim the White House in 2020. If upheld on appeal, the decision could deprive an estimated 17 million Americans of their health insurance — including millions who gained coverage through the law’s expansion of Medicaid. Still others could see premiums skyrocket as price protections for preexisting conditions lapse.
The immediate practical effect of the ruling was not clear. While the judge declared that the whole law was invalid, as Texas and 19 other states had asserted, he did not issue an injunction to stop federal officials from enforcing it, and the effects of the judgment could be delayed pending appeals.
But the timing of the decision seemed designed to maximize political reverberations. It came a day before open enrollment was to end for coverage under the health law for the coming year. Sign-ups were already expected to dip after successive blows to the law by Congress and the Trump administration. But the passage of statewide referendums in November and the election of Democratic governors could also mean coverage expansions in the coming year under the health law’s Medicaid expansion.
In an e-mail to millions of Americans on Saturday, the Trump administration tried to allay concerns caused by the court decision in the Texas case.
The case is “still moving through the courts,” said the message from the federal Centers for Medicare and Medicaid Services. “The marketplaces are still open for business, and we will continue with open enrollment. There will be no impact to enrollees’ current coverage or their coverage in a 2019 plan.”
But President Trump was in a celebratory mood, tweeting, “Wow, but not surprisingly, Obamacare was just ruled UNCONSTITUTIONAL by a highly respected judge in Texas. Great news for America!”
In his ruling Friday, Judge Reed O’Connor of the US District Court in Fort Worth struck down the law on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it. The judge found that the “myriad parts” of the law are all interconnected. Without the mandate, he said, the rest of the law comes crashing down.
The ruling is just the latest chapter in the tumultuous history of a law that has transformed life for millions of Americans since the measure was passed without any Republican votes and signed in March 2010 by President Obama.
The decision puts Republicans in Congress into a political box. Most of them tried over and over to repeal the Affordable Care Act. And many of them survived the Democratic wave in November’s midterm elections only by vowing to preserve the law’s protections for people with preexisting conditions — protections that would be swept aside by O’Connor.
“Republicans in office would mostly prefer to run away from this issue or hope it disappears before they have to deal with it legislatively,” said Thomas P. Miller, a lawyer and health economist at the American Enterprise Institute and a critic of the law.
Recent polls have found that slightly more than half of Americans approve of the Affordable Care Act, with many more, across political persuasions, wanting to keep its provisions protecting people with preexisting health conditions. But polls have also found that many Americans are unhappy with their health care and its costs, particularly drug prices, and both parties in Congress have taken note.
Under the Affordable Care Act, many people of modest means can obtain subsidies covering all of their premiums, so the insurance is essentially free. But for those whose income is too high to qualify for subsidies, the costs remain high — a problem that the Trump administration and congressional Republicans have seized on.
Encouraging enrollment under the Affordable Care Act has never been a priority for Trump administration officials, and confusion caused by the court decision in Texas could further depress enrollment, which was already lagging behind last year’s numbers.
This year’s enrollment period is now ending except for in Rhode Island, where it will end Dec. 23, and in California, Colorado, Massachusetts, Minnesota, New York, and the District of Columbia, where it will end in January.