How Pending Decision on Obamacare Could Upend 2020 Campaign

WASHINGTON — A federal appeals court in New Orleans is preparing a ruling on the Affordable Care Act that could put the law’s future front and center in the presidential race, overwhelming the current Democratic debate over Medicare for all and reigniting the health care-driven worries that helped Democrats win back the House last year.

Three judges on the Fifth Circuit Court of Appeals are weighing whether to uphold a Texas judge’s ruling that the law’s requirement for most Americans to have health insurance is unconstitutional, and that the rest of the sprawling law cannot function without it. It is hard to imagine a thornier domestic issue for President Trump, whose administration not only refused to defend the law in the case filed by Texas and 19 other states but sided with the plaintiffs, asking the court to invalidate it.

A ruling against Barack Obama’s signature domestic achievement as president, which provides health coverage for about 24 million Americans, would almost certainly be stayed pending further appeal.

But if it comes in the next few weeks, it could create significant confusion during open enrollment for the Obamacare plans offered through the law’s online marketplaces. And it would open a huge vulnerability for Mr. Trump, whose health care platform largely consists of attacking as socialism Democratic plans to expand government health care, either through Medicare for all or a government-run health care option that would be offered through the Affordable Care Act’s marketplaces.

A ruling against the health law would probably reframe the Democratic conversation on health policy away from moving beyond the Affordable Care Act toward Republican efforts to take health care away. That message, a driving force in the 2018 midterm campaigns, could resonate more broadly than the party’s current arguments over expanding coverage.

“Democrats will do better talking about what Trump can take away than about their new policy visions,” said Chris Jennings, a longtime Democratic adviser on health care. “The Texas case may reframe discourse around health policy more toward that type of discussion, which of course Republicans will hate.”

The law’s most popular provision is protections for people with pre-existing medical conditions, but it includes much more, such as health insurance exchanges where people can buy private coverage with subsidies, an expansion of Medicaid and requirements for what insurance must cover, from emergency services to prescription drugs.

The appeals court panel could decide to partly reverse Judge Reed O’Connor of the Federal District Court in Fort Worth, affirming that the mandate that most Americans have health insurance is unconstitutional but rejecting Judge O’Connor’s ruling that the rest of the law cannot stand without it. That would cause barely a ripple, because the tax penalty for not having insurance was reduced to zero in the 2017 tax overhaul and the effects have been negligible.

But a ruling that upheld his decision in full, or even one that said the mandate and pre-existing condition protections had to go, would send shock waves through the health care and political systems. Either outcome would probably play into Democratic hands, especially in contests against vulnerable Republicans like Senators Martha McSally of Arizona, Cory Gardner of Colorado, Susan Collins of Maine and Thom Tillis of North Carolina.

Republicans are not conceding that possibility. Asked how a ruling against the law might affect members of the party seeking re-election, the spokesman for the House Republican campaign arm, Chris Pack, said: “Both Democrats and Republicans oppose Obamacare. The only difference is that Democrats want to replace it with socialized single-payer health care that makes private health insurance illegal.”

In fact, most Democrats would welcome a renewed debate over the Affordable Care Act. Many Democrats in Congress have resisted Medicare for all; instead they have sought to shore up the existing health law and trap Republicans on pre-existing conditions. Senator Chuck Schumer of New York, the Democratic leader, intends to force a floor vote as soon as next week on a resolution to overturn a Trump rule that lets states promote skimpy-but-inexpensive insurance plans that do not meet the law’s coverage standards.

The vote, Mr. Schumer said Tuesday on the Senate floor, “will present our Republican colleagues with a choice: whether to protect Americans with pre-existing conditions or not to protect them.”

Mr. Trump is in a box on health care, the issue that registers as a top priority for voters in poll after poll. He wants deals on ending surprise medical bills and lowering prescription drug prices, but the Senate and House are far apart on what drug price legislation they would agree to, and impeachment proceedings could derail any chance of bipartisan measures.

Public support for the health law remains high, driven in part by swing voters. And few Americans believe Mr. Trump will offer details of a new health care plan before the end of the year, according to a Kaiser poll released this week. They also doubt any plan he releases would offer “better care at lower costs,” as he has promised.

Alex M. Azar II, the secretary of health and human services, has repeatedly played down the importance of expanding coverage to the remaining uninsured; instead, he has said, Mr. Trump wants to improve the health care system for all Americans. His efforts thus far have mostly been directed at discrete groups of patients: a plan to reduce new H.I.V. infections by 75 percent over five years, for example, and another to move people with advanced kidney disease to home-based, instead of clinic-based, dialysis.

At oral arguments before the appeals court panel in July, a lawyer from the Justice Department indicated the Trump administration would seek a stay if the panel upheld Judge O’Connor’s decision. The losing side could appeal directly to the Supreme Court, increasing the chances of a ruling or at least oral arguments before that court in the final months of the presidential campaign. Alternatively, it could first ask for a hearing by the full appeals court, which would slow down the process.

The appeals panel could also send the case back to Judge O’Connor to reconsider, an option that August Flentje, a lawyer for the Justice Department, embraced during oral arguments. That would also draw out the court fight.

When the six-week open enrollment period starts next month, there will be more insurers offering plans through the Affordable Care Act markets. Premiums have stabilized, too, after a few years of price increases. But it will be a much lower-profile effort than in past years; the Trump administration has cut the budget for both advertising and enrollment help. As a result, a court ruling against the law would paralyze open enrollment if people assume there is no use buying or renewing coverage under a law that was ruled unconstitutional, and if no effort is mounted to counter that misunderstanding.

“It will require a doubling down, a dramatic increase in education — which is exactly the opposite of what this administration has done,” said Leslie Dach, executive director of Protect Our Care, a consumer advocacy group aligned with Democrats. “Someone will need to educate people that low-cost, quality health insurance is still available to them.”

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