Physicians, Patients Vow to Overturn Ruling Striking Down ACA

Alicia Ault

Disclosures

December 15, 2018

Almost as soon as a Texas judge ruled yesterday that the Affordable Care Act (ACA) is unconstitutional, proponents of the law — including physicians' organizations, which had filed briefs in support — vowed to appeal the decision.

"Today's decision is an unfortunate step backward for our health system that is contrary to overwhelming public sentiment to preserve pre-existing condition protections and other policies that have extended health insurance coverage to millions of Americans," said Barbara L. McAneny, MD, president of the American Medical Association (AMA), in a statement sent to Medscape Medical News.

The AMA led a coalition — including the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry — in filing an amicus brief in support of the law.

McAneny said the AMA will work with patient advocates and others to pursue an appeal.

"The scope of this order is just so breath-taking," said Timothy S. Jost, professor emeritus at the Washington and Lee University School of Law in Lexington, Virginia, noting that striking the law would have huge repercussions. "I think it's extremely likely this decision will be reversed," Jost told Medscape Medical News.

Law Said to Exceed Congress' Authority

Judge Reed O'Connor of the US District Court for the Northern District of Texas said in his December 14 opinion that, "The Court finds that the Individual Mandate can no longer be fairly read as an exercise of Congress' tax power and is still impermissible under the Interstate Commerce Clause — meaning the Individual Mandate is unconstitutional."

He further found that the mandate was essential to the ACA, and thus, without it, that the law should no longer stand.

O'Connor did not grant the plaintiffs' request to immediately overturn the ACA. That means nothing will change between now and January 1, when, by law, the individual mandate is slated to end.

But it's unclear what will happen after that. "I kind of think we're in uncharted territory here," said Jost.

The Trump administration could choose to accept the ruling as the new law of the land, which would mean throwing out the ACA. Given the ACA's scope, that could have massive ripple effects — from ending US Food and Drug Administration authority to approve generic drugs, to re-opening the donut hole for Medicare prescription drugs, to eliminating the Medicaid expansion, Jost told Medscape Medical News.

The administration also could wait to see whether the ruling is upheld on appeal. In the meantime, defenders of the law will have to petition to keep O'Connor's ruling from going into effect.

"Possibly, the federal government will attempt to get a stay because this goes far beyond what they asked for," Jost said, adding that, given the timing of the ruling and its potential effects, that perhaps it was designed to sow confusion.

O'Connor's ruling came just one day before the 2019 enrollment period for the 39 states using the ACA federal health exchange was coming to an end — even though the Trump administration during oral arguments in September had asked O'Connor to hold off until after enrollment closed.

President Donald J. Trump lauded O'Connor's ruling. "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 said in a tweet.

House Speaker-Designate Nancy Pelosi (D-California) had an immediate response. "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," she said in a statement.

States Vow to Appeal

The Texas ruling is the result of a lawsuit filed in February 2018 by 20 states that claimed the ACA was unconstitutional because a tax overhaul bill signed into law last December removed the individual mandate.

The Trump administration — through its Department of Justice — said it would not defend key parts of the law, including the individual mandate and protections for people with pre-existing conditions.

That prompted a coalition of 16 states and the District of Columbia, led by California, to jump in to defend the ACA.

After O'Connor's ruling, California Attorney General Xavier Becerra said in a statement, "Today's misguided ruling will not deter us: our coalition will continue to fight in court for the health and wellbeing of all Americans." 

Becerra also called the judge's ruling "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."

Health Groups Express Outrage

Patient and healthcare professional groups also expressed concern about how elimination of all or part of the ACA could jeopardize the nation.

"This decision threatens to resurrect barriers to health care for people with serious illnesses including cancer, heart disease, stroke, lung disease, diabetes and those with neurological conditions," said the American Cancer Society Cancer Action Network, the American Diabetes Association, the American Heart Association, the American Lung Association, and the National Multiple Sclerosis Society in a joint statement.

The groups said that if the ruling stands, people with pre-existing conditions could be denied coverage or charged more, and that health plans could impose annual and lifetime limits on coverage.

"The court should have respected the will of Congress, instead of ruling to invalidate the law at the expense of the 27 million Americans who will lose their health care by 2020, according to Congressional Budget Office estimates," they said.

Vincent DeMarco, president of the Maryland Citizens' Health Initiative, said in a statement that "if the ruling is upheld by a higher court, 3.5 million Marylanders could lose their health care coverage or face higher premiums due to their age, gender, or a pre-existing condition."  

The Federation of American Hospitals (FAH) "believes this ruling would have a devastating impact on the patients we serve and the nation's health care system as a whole," said FAH President and CEO Chip Kahn in a statement.

"Having this decision come in the closing hours of open enrollment also sows seeds of unnecessary confusion," said Kahn, adding, "We strongly believe this should be overturned in the appeals process."

ACA Opponents Happy

The ruling brought applause in some quarters.

"Obamacare was truly one of the worst pieces of legislation ever passed by Congress," said Adam Brandon, president of FreedomWorks, in a statement, adding that the law left many unable to afford healthcare. 

"The individual mandate was the centerpiece of Obamacare. Without that tax, the law can no longer stand," said Brandon.

"The embarrassingly designed ACA was hastily written by Democrats behind closed doors and stuffed with special interest giveaways that drove up health care costs for millions of working Americans. It's been a disaster since its partisan and unpopular inception," said House Ways and Means Committee Chairman Kevin Brady (R-Texas), in a statement.

"Should the courts ultimately uphold this decision both parties should start over, working together to make health care truly affordable, making sure patients can see local doctors and be treated at local hospitals, and ensuring that patient protections like pre-existing conditions, no lifetime limits, and allowing children to stay on their parents plans until age 26 are preserved," said Brady.

Republican colleague Greg Walden (Oregon), chairman of the House Energy and Commerce Committee, took a more moderate tone. "While today's 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, increases transparency and choice, and lowers costs," he said, in a statement.

"I urge my Democratic colleagues to work with Republicans to finally enact patient-centered reforms to our nation's health care system," Walden said.

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