Late on Dec. 14, a federal court judge in Texas issued a stunning ruling finding the entire Affordable Care Act (ACA) unconstitutional. In a case brought against the ACA by 20 Republican-led states, U.S. District Court Judge Reed O’Connor ruled that the ACA’s individual mandate requiring that people buy health insurance is unconstitutional and that Congress “sawed off the last leg” the law stood on when it repealed the mandate in 2017. Judge O’Connor stated that the mandate “is essential to” and inseparable from all of the ACA’s key provisions and, therefore, all the ACA’s provisions are invalid. If the ruling stands up to court challenges, the entire U.S. health system will be significantly affected, with subsidies for individual coverage through state ACA marketplaces, state Medicaid expansions and protections for people with pre-existing conditions ended. However, the judge did not issue any injunctions, which means that all parts of the law are unaffected in 2019, including marketplace insurance coverage.

California and the 16 other states that defended the ACA in the case have stated that they will challenge O’Connor’s ruling through the U.S. Court of Appeals. The Texas ruling has brought the ACA back into focus in Washington, with the President calling on Congress to pass a “great health care solution.” A Trump administration spokesperson said that the ACA will remain in place while the legal process continues. Congressional Democrats are preparing to advance legislation that firms up coverage protections and clarifies congressional intent with respect to ACA pre-existing conditions provisions.

Legal experts are predicting that the Texas ruling will be overturned by higher courts in part due to the judge’s unique interpretation of Congress’s intent when it repealed the individual mandate but expressly did not repeal the rest of the law, including key patient protections. We expect that Congress will again consider some health care reform legislation designed to protect the ACA.