WASHINGTON -- The decision by a federal judge in Texas to strike down the Patient Protection and Affordable Care Act, imperiling the insurance coverage of millions of Americans, has turned the health care debate into a pressing issue for Congress.
After Democrats campaigned vigorously on a pledge to protect patients with pre-existing medical conditions -- a promise that has helped return them to the House majority they lost in 2010 -- the party vowed to move swiftly to defend the law and to safeguard its protections.
Saturday was the open-enrollment deadline for residents of most states to obtain coverage under the health law for 2019.
The Friday ruling, if it stands, not only does away with coverage protections for people with pre-existing health conditions, but it also strikes 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 the ruling 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 outcry from the Texas decision, though, is not likely to diminish anytime soon.
"This is a five-alarm fire," said Sen. Chris Murphy, D-Conn. "Republicans just blew up our health care system."
Republicans were muted in their response, but incoming House Minority Leader Kevin McCarthy of California appealed to Democrats to help in negotiating a successor to what he called "an unconstitutional law."
"President [Donald] 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, when Democrats gain control of the House.
Democrats also intend to convene hearings to spotlight the sweeping effect of the Texas ruling. If upheld on appeal, the decision would threaten the health insurance of an estimated 17 million Americans -- including millions who gained coverage through the law's expansion of Medicaid. Still others could see premiums skyrocket as price protections for pre-existing conditions lapse.
In his ruling Friday, Judge Reed O'Connor of the U.S. 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 a big win for Arkansans," state Attorney General Leslie Rutledge said in a statement Saturday. "Without the individual mandate in place, Obamacare cannot be upheld and is unconstitutional. Now, it is time for Congress to increase options, lower costs and protect those with pre-existing conditions."
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, including Arkansas, 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.
In an email to millions of Americans on Saturday, the Trump administration tried to allay concerns caused by the court decision.
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 Trump was in a celebratory mood. "It was a big, big victory by a highly respected judge, highly, highly respected in Texas, and on the assumption that the Supreme Court upholds, we will get great, great health care for our people," Trump told reporters Saturday. "We'll have to sit down with the Democrats to do it, but I'm sure they want to do it also."
ANALYSTS' CRITICISM
On Saturday, the ruling came under attack from legal analysts who predicted that higher courts will reject the rationale as an effort to rewrite not just the law but congressional history.
The judge's ruling flouts settled legal doctrine and places key acts of Congress in reverse order, said Yale law professor Abbe Gluck, who filed an amicus brief with other lawyers in the Texas case.
By ignoring that Congress declined to strike down the Affordable Care Act in 2017 when it chose to alter only one portion of the bill, she said, the judge decreed that the 2010 Congress, which first passed the law, has more authority than the same legislative body in 2017.
"It's absolutely ludicrous to hold that we do not know whether the 2017 Congress would have wanted the rest of the ACA to exist without an enforceable mandate, because the 2017 Congress did exactly that when it zeroed out the mandate and left the rest of the ACA standing," Gluck said. "He effectively repealed the entire Affordable Care Act when the 2017 Congress decided not to do so."
Ted Frank, a lawyer at the Competitive Enterprise Institute who is critical of the health care law, called the decision "embarrassingly bad" because "you're twisting yourself into knots" to reach a particular conclusion.
Over the past two years, Frank said, conservative lawyers such as he have complained when district judges did similar intellectual gymnastics to attack Trump administration initiatives. "It's not appropriate in the other direction, either," he said.
Nicholas Bagley, a University of Michigan law professor, predicted "a long slog" while the courts wrestle with O'Connor's decision.
"I think this case is frivolous, and I think the judge's opinion is about as naked a piece of judicial activism as I have ever seen; I don't even think it's close," said Bagley, who supports the Affordable Care Act. "Like any lawsuit, you should take it seriously, but I don't think this is an imminent or mortal threat to the Affordable Care Act."
After struggling for eight years to come up with an alternative to the Affordable Care Act, some Republicans in Congress expressed hope that the judge's decision would be a catalyst for cooperation, which has been virtually nonexistent to date.
"While the ruling will certainly be appealed and will not impact insurance premiums or plans for next year, we have a rare opportunity for truly bipartisan health care reform that protects those with pre-existing conditions," said Rep. Greg Walden, R-Ore., departing chairman of the Energy and Commerce Committee.
Sen. Bill Cassidy, R-La., said the court ruling showed the need for a bill such as one he introduced in 2017 with Sen. Susan Collins, R-Maine. The bill would keep consumer protections from the Affordable Care Act but give states much more discretion over the use of federal funds for health care.
"Obamacare is failing," said Cassidy, who is a medical doctor. "People are going without insurance because they can't afford it. Democrats may be doing the political calculus, saying, 'This is great for us because we want to use the issue in 2020.' But I don't care about the politics. I'm concerned about that family of four in Louisiana who don't get a subsidy, who are paying $40,000 a year for a policy with a $13,000 deductible."
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.
From Nov. 1 to Dec. 8, about 4.1 million people had signed up for coverage through the federal marketplace, with new enrollment in the 39 states that use the federal website healthcare.gov down by 20 percent compared with the same period last year.
In all, 11.8 million people in the U.S. signed up for health insurance through the law's marketplaces for 2018. This year's enrollment period has ended in most states; six states and Washington, D.C., have later deadlines.
Information for this article was contributed by Sheryl Gay Stolberg, Robert Pear and Abby Goodnough of The New York Times; and by Devlin Barrett of The Washington Post.
A Section on 12/16/2018