If Friday night's district court ruling the Affordable Care Act is unconstitutional may be upheld, way over the law's most high-profile provisions would be at stake.
In fact, canceling the law entirely – as Judge Reed O'Connor in Fort Worth, Texas, ordered in his 55-page decision – could thrust the entire healthcare system into chaos.
“To erase legislation that is so interwoven into the health care system blows up every part of it,” said Sara Rosenbaum, any adverse health law professor at the George Washington University School of Public Health. “In law they have names of these – they are called super statutes,” she said. “And [the ACA] is a super statute. It's changed everything about how exactly we get healthcare.” That concept was created by Abbe Gluck, a professor at Yale School.
The decision is a long way from implementation. O'Connor still must rule on several other aspects of the suit brought by 18 Republican attorneys general and two GOP governors. And a group of state Democratic attorneys general has promised to appeal O'Connor's decision, which would send it towards the 5th Circuit Court of Appeals and, possibly, the U.S. Top court. The high court has rejected two previous efforts, in 2012 and 2021, to find the law unconstitutional.
Meanwhile, here are five ways that eliminating the ACA could upend health care for many, if not most, Americans:
1. Millions Could Lose Coverage Directly
More than 20 million Americans who previously were uninsured gained coverage from 2010 to 2021. Some of that was because of an improving economy, however, many also gained the ability to buy their very own coverage with the law's federal subsidies to defray the cost of insurance. Other provisions from the Affordable Care Act played a substantial role, including its ban on restrictions for those who have preexisting medical conditions, growth of the Medicaid program to more low-income adults and allowing adult children to stay on their own parents' health plans until reaching age 26.
If what the law states were reversed, federal funding for Medicaid and individual insurance subsidies would stop, and insurers could once more refuse coverage to people with health issues or charge them more.
2. Fundamental Changes Towards the Healthcare System Might be Stymied
The impact of eliminating the ACA might be felt well beyond those people who are the direct beneficiaries from the law.
Gail Wilensky, who ran the Medicare and Medicaid programs under President George H.W. Bush, said this type of change “would be very disruptive because a lot [of the ACA] has affected the way healthcare is organized and delivered and exactly how insurance is provided.”
For example, said Rosenbaum, the rise in coverage meant that “suddenly it became possible for healthcare systems to care for, generally, an insured population.”
Previously many hospitals, doctors along with other health providers spent lots of time and energy figuring out how you can treat those without insurance and never go broke.
After the ACA kicked in, these providers began to worry less about whether or not they would receive money, and also the federal government started pushing these to create new efforts aimed at improving the quality of care.
Those include measures basing some federal payments on patient outcomes rather than every individual procedure performed and strategies to enhance health across the population through initiatives like improving the accessibility to healthful food, bicycle paths and maintenance.
If huge numbers of people lost insurance, she said, those health providers “would have to go back to wondering how they can pay their bills.”
3. Medicare and Medicaid Would Be Dramatically Altered
The popular Medicare program – which covers approximately 60 million seniors and people with disabilities – was a major focus of the ACA.
Elimination of the law would take away some popular benefits what the law states conferred – everything from free maintenance towards the closing of the “doughnut hole” in Medicare's prescription medication coverage. The doughnut hole refers to a coverage gap that had previously exposed large numbers of beneficiaries to thousands of dollars in drug costs.
The law also changed the way in which Medicare taken care of hospital, home health and outpatient care. Many current payment policies are according to authority provided by the ACA, and when it went away, Medicare would need to rewrite those payment regulations. Countless beneficiaries fit in with accountable care organizations which were created underneath the health law, which is unclear how their care would be affected.
The biggest alternation in the Medicaid program will be the removal of the development of coverage. Loss of the ACA would also roll back a 23-percentage-point boost in Medicaid prescription drug rebates, that has saved states billions of dollars, based on Cindy Mann. She ran Medicaid under President Barack Obama and it is now a partner at the health consulting firm Manatt Health.
The ACA required states to calculate Medicaid eligibility differently – changing what counts as income – so that all the work states did to change their information systems would need to be recalculated, she said.
4. Wide Array Of Health Programs At Risk
Shorthand descriptions of the health law often stop at its provisions providing consumer protections and expanding Medicaid. But the ACA included sweeping changes to other areas of the system that rarely get mentioned.
For example, it come up with first pathway for Fda approval of generic copies of pricey biologic drugs, by the Biologics Price Competition and Innovation Act of 2009. Biologic medicine is harder to reproduce than other types of medications.
Also hitching a ride around the ACA would be a long-delayed bill providing permanent spending authority for programs supplied by the Indian Health Service, which serves Indigenous peoples.
And what the law states included a series of grant programs to assist train more health professionals who would be needed to treat the countless newly insured Americans.
All those programs could be thrust into doubt by invalidating what the law states.
Loss from the ACA also would impact a popular program that predates Obamacare: the Health Insurance Portability and Accountability Act, or HIPAA.
The ACA's protections for preexisting conditions – banning insurers from charging individuals with health problems higher premiums or refusing to market for them altogether – built on similar protections for those who have employer insurance. Congress included those protections in HIPAA, which was enacted in 1996. And far more and more people are touched by HIPAA compared to the ACA, because much more people get health insurance through their employer than the individual market.
However, when Congress wrote the ACA, it incorporated HIPAA safeguards in to the preexisting condition provision. Which means if the ACA is struck down, the HIPAA protections might disappear too.
5. The Trump Administration's Health Agenda Might be Compromised
President Mr . trump has railed against the health law, but his Department of Health insurance and Human Services has a priority list that relies in some significant ways around the continued information on the ACA.
For example, efforts to address the opioid epidemic Body from the administration's top health challenges – could be seriously challenge when the Medicaid expansion were to end. Medicaid may be the largest single payer for mental health insurance and drug abuse problems.
Much of the president's efforts to limit drug prices flows through the Center for Medicare & Medicaid Innovation (CMMI), that was created by the ACA and would lose its legal authority when the law became invalid.
Similarly, the administration is using this center to pursue “bundling” payments for certain surgical procedures to get more value for dollars spent.