A federal judge in Texas said on last Friday that the Affordable Care Act's individual coverage mandate is unconstitutional and that the rest of the law therefore cannot stand.
Legal experts say the ruling won't immediately affect Americans' health coverage, and a group of states led by California is already vowing to appeal. But the invalidation of the landmark health care law popularly known as Obamacare throws into doubt the future of health coverage for millions of Americans on the Obamacare exchanges and in Medicaid expansion.
The ruling and expected appeal sets up another cliffhanger in which the fate of the law, which Republicans have unsuccessfully tried to repeal for years, will likely once again ultimately lie with the Supreme Court.
Chief Justice John Roberts cast the deciding vote leaving the law intact in 2012, but it's unclear how the justices will view this challenge, which centers on changes to the individual mandate that were baked into the 2017 tax reform.
President Donald Trump, who campaigned in 2016 on a promise to undo Obamacare, was thwarted in Congress last year by a lone vote from the late Arizona Republican Sen. John McCain.
Trump immediately tweeted in celebration on Friday and called on Congress to act.
"As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster! Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!" Trump wrote.
He later added, "Wow, but not surprisingly, ObamaCare was just ruled UNCONSTITUTIONAL by a highly respected judge in Texas. Great news for America!"
On Saturday, Trump told reporters that if the decision is eventually upheld by the Supreme Court, "we will be sitting down with the Democrats" to "get great health care for our people."
"Let's say repeal and replace, handled a little bit differently, but it was a big, big victory by a highly respected judge," Trump said during a visit to Arlington National Cemetery.
Later Saturday, Obama took to Facebook to urge people to enroll in the program, writing in a post that Friday's ruling "can be a scary thing to hear, particularly if you or someone you care about has a pre-existing condition."
"As this decision makes its way through the courts, which will take months, if not years, the law remains in place and will likely stay that way," he wrote.
Democratic House leader Nancy Pelosi decried the ruling and suggested that the coming Democratic-led House will intervene in the case.
"Republicans are fully responsible for this cruel decision and for the fear they have struck into millions of families across America who are now in danger of losing their health coverage," Pelosi said in a statement released late Friday. "When House Democrats take the gavel, the House of Representatives will move swiftly to formally intervene in the appeals process to uphold the life-saving protections for people with pre-existing conditions and reject Republicans' effort to destroy the Affordable Care Act."
Today, the law governs American health care.
More than 4 million people have already signed up for 2019 coverage on the exchanges, and millions more are expected to pick plans before open enrollment ends Saturday.
The ruling threatens to wipe away the Affordable Care Act's protections for those with pre-existing conditions, which became a focal point of the midterm elections and helped Democrats take the House.
In his opinion, District Judge Reed O'Connor said the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional."
He also held that the individual mandate is "essential to and inseverable from the remainder of the ACA."
The case against the ACA was brought by 20 Republican state attorneys general and governors, as well as two individuals. It revolves around Congress effectively eliminating the individual mandate penalty by reducing it to $0 as part of the 2017 tax cut bill. The mandate requires nearly all Americans to get health insurance or pay a penalty.
The Republican coalition, led by Texas Attorney General Ken Paxton, is arguing that the change rendered the mandate itself unconstitutional. The states say that the voiding of the penalty, which takes effect next year, removes the legal underpinning the Supreme Court relied upon when it upheld the law in 2012 under Congress' tax power.
The Trump administration said in June that it would not defend several important provisions of Obamacare in court. It agreed that zeroing out the penalty renders the individual mandate unconstitutional but argued that invalidates only the law's protections of those with pre-existing conditions. These include banning insurers from denying people policies or charging them more based on their medical histories, as well as limiting coverage of the treatment they need.
But the administration maintained those parts of the law were severable and the rest of the Affordable Care Act could remain in place.
Professor Tim Jost, of Washington and Lee University, noted that O'Connor went further than the Trump administration had asked.
"The Trump administration only asked that the individual mandate and provisions protecting individuals with pre-existing conditions be invalidated, but O'Connor's order would invalidate many provisions of the Medicaid program, the Medicare program and other federal laws," he told CNN.
But Jost said the structure of the challenge and of O'Connor's ruling means that nothing will change right away.
"Judge O'Connor has declared the individual mandate unconstitutional and the rest of the Affordable Care Act invalid, but he has not blocked its continued operation," Jost said.
It's unclear what will happen to those customers in the future. Nearly 10.3 million people got their insurance this way in 2018.
If the ruling stands, millions may have to find insurance another way, if they can. Obamacare was created in part so people could find a plan that was affordable and would cover them even if they had a pre-existing condition.
Obamacare also expanded who was eligible for Medicaid. If the law is completely struck down, their insurance could also be in jeopardy. Nearly 10 million additional Americans gained coverage through the Medicaid expansion.
Who else would be affected?
"The ACA is pretty baked into our health care system now," said Karen Pollitz, a senior fellow and expert on health reform and private insurance with the Kaiser Family Foundation. "Making it go away is not that easy."
Essentially, anyone who uses the health care system could be affected. The nearly 2,000-page law radically reshaped the system.
Under Obamacare, employers with 50 employees or more had to offer benefits to those who work more than 30 hours a week.
The law also changed the quality of care that insurance had to cover. Under Obamacare, health insurance plans must carry 10 essential benefits that include emergency services, hospitalization, pregnancy, mental health, prescription drugs, lab work, rehab, outpatient care, preventive care such as birth control, mammograms and cholesterol tests. Pediatric services such as dental and vision care are also included.
People up to the age of 26 were also allowed to stay on their parents' health insurance under Obamacare.
Obamacare eliminated lifetime limits, meaning policies can't be maxed out. And the 133 million people with pre-existing conditions could no longer be turned away or charged more by insurance companies. Previously, even people with acne could be denied coverage.
It improved benefits for Medicare Advantage enrollees, slowed the growth of payment rates to hospitals and offered preventive health care free to Advantage patients.
And there are initiatives that go far beyond what you'd see with your own insurance. Obamcare set up plans to address waste, fraud and abuse in the system. It created a CMS innovation center that tests ways to save money on health expenses. It held hospitals more accountable. It created taxes that helped pay for the programs. There were new financial disclosure rules for doctors and pharmacists. Nonprofit hospitals had to conduct community assessments and make sure they were meeting the health needs of the community.
"The law is extensive and goes far beyond coverage and financial assistance for patients,"