Sheryl Gay Stolberg, Robert Pear and Abby Goodnough

After campaigning vigorously on a pledge to protect patients with pre-existing medical conditions — a promise that helped return them to the House majority they had lost in 2010 — Democrats vowed to move swiftly to defend the law and to safeguard its protections.

On the defensive, Republicans campaigning this fall promised that they too backed the health law’s protections for people with pre-existing medical conditions. But the Texas ruling illustrated the fruits — and possible perils — of their long-running campaign, stepped up in the Trump era, to remake the judiciary through the confirmation of dozens of conservative judges, including two appointees to the Supreme Court.

The ruling, if it stands, would not only do away with coverage protections for people with pre-existing health conditions but also strike down the guarantee of coverage for what the law deems “essential health benefits.” These include emergency services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs and pediatric care.

But it is so sweeping that many legal analysts believe it is likely to be overturned. The Supreme Court, in a 5-4 decision, has already upheld the Affordable Care Act’s legality. The political reaction to the Texas decision, though, is not likely to diminish anytime soon.

“This is a five-alarm fire,” said Sen. Chris Murphy, D-Conn. "Republicans just blew up our health care system.”

Top Republicans were by and large muted in their response, but incoming House Minority Leader Kevin McCarthy of California appealed to Democrats to come to negotiate a successor to what he called “an unconstitutional law.”

“President Trump has made clear he wants a solution, and I am committed to working with my colleagues on both sides of the aisle to make sure America’s health care system works for all Americans,” he said in a statement Saturday.

The Democrats’ first step will be in the courts; aides to current House Minority Leader Nancy Pelosi of California said Saturday that House Democrats would move quickly to notify the Trump administration that they intend to intervene in the case. A vote on a resolution to do so is expected in the earliest days of the new Congress.

Democrats also intend to convene hearings to spotlight the sweeping impact of the Texas ruling — and lay the groundwork for their case to reclaim the White House in 2020. If upheld on appeal, the decision could deprive an estimated 17 million Americans of their health insurance — including millions who gained coverage through the law’s expansion of Medicaid. Still others could see premiums skyrocket as price protections for pre-existing conditions lapse.

The immediate practical effect of the ruling was not clear. While the judge declared that the whole law was invalid, as Texas and 19 other states had asserted, he did not issue an injunction to stop federal officials from enforcing it, and the effects of the judgment could be delayed pending appeals.

But the timing of the decision seemed designed to maximize political reverberations. It came a day before open enrollment was to end for coverage under the health law for the coming year. Sign-ups were already expected to dip after successive blows to the law by Congress and the Trump administration. But the passage of statewide referendums in November and the election of Democratic governors could also mean coverage expansions in the coming year under the health law’s Medicaid expansion.

In an email to millions of Americans on Saturday, the Trump administration tried to allay concerns caused by the court decision in the Texas case.

The case is “still moving through the courts,” said the message from the federal Centers for Medicare and Medicaid Services. “The marketplaces are still open for business, and we will continue with open enrollment. There will be no impact to enrollees’ current coverage or their coverage in a 2019 plan.”

But President Donald Trump was in a celebratory mood. “It was a big, big victory by a highly respected judge, highly, highly respected in Texas, and on the assumption that the Supreme Court upholds, we will get great, great health care for our people,” Trump told reporters Saturday. “We’ll have to sit down with the Democrats to do it, but I’m sure they want to do it also.”

In his ruling Friday, Judge Reed O’Connor of the U.S. District Court in Fort Worth struck down the law on the grounds that its mandate requiring people to buy health insurance is unconstitutional and the rest of the law cannot stand without it. The judge found that the “myriad parts” of the law are all interconnected. Without the mandate, he said, the rest of the law comes crashing down.

The ruling is just the latest chapter in the tumultuous history of a law that has transformed life for millions of Americans since the measure was passed without any Republican votes and signed in March 2010 by President Barack Obama.

The decision puts Republicans in Congress into a political box. Most of them tried over and over to repeal the Affordable Care Act. And many of them survived the Democratic wave in November’s midterm elections only by vowing to preserve the law’s protections for people with pre-existing conditions — protections that would be swept aside by O’Connor.

“Republicans in office would mostly prefer to run away from this issue or hope it disappears before they have to deal with it legislatively,” said Thomas P. Miller, a lawyer and health economist at the American Enterprise Institute and a critic of the law.

After struggling for eight years to come up with an alternative to the Affordable Care Act, some Republicans in Congress seemed to hope that the judge’s decision would be a catalyst for cooperation, which has been virtually nonexistent to date.

Rep. Greg Walden, R-Ore., departing chairman of the Energy and Commerce Committee, said the decision offered “a rare opportunity for truly bipartisan health care reform that protects those with pre-existing conditions.”

In the Senate, two Republicans who have cooperated on health legislation — Susan Collins of Maine and Bill Cassidy of Louisiana — said in separate interviews that the ruling showed the need for a bill like one they introduced in 2017. The bill would keep consumer protections from the Affordable Care Act but give states much more discretion over the use of federal funds for health care.

“Obamacare is failing,” said Cassidy, who is a medical doctor. “People are going without insurance because they can’t afford it. Democrats may be doing the political calculus, saying, ‘This is great for us because we want to use the issue in 2020.’ But I don’t care about the politics. I’m concerned about that family of four in Louisiana who don’t get a subsidy, who are paying $40,000 a year for a policy with a $13,000 deductible.”

Collins, who has sought unsuccessfully to persuade the Justice Department to defend the law’s provisions on pre-existing conditions, predicted that the Texas ruling would be overturned, but said the Senate needed to press ahead with legislation even if it was not.

“I was surprised that the judge was so sweeping in his decision,” she said. “There was no need for him to strike down the entire ACA. He could have taken a much more surgical approach.”

Others were taking a wait-and-see attitude. Rep. Tom Cole, R-Okla., said Saturday that he and his colleagues would wait until they saw the outcome of the lawsuit before reacting.

“They think they can whip people up over the health care issue; it worked well for them in the midterms,” Cole said, referring to Democrats. “But we are two years away from the election, and I think very seldom does something happen in this time frame that has lasting political impact.”

Friday’s decision could also give a boost to liberal Democrats who won hotly contested races running as advocates of “Medicare for all.” Even before Friday’s court decision, liberals were promising to make health care a central issue in the next presidential election.

“Democrats need to put a bright North Star in the sky for 2020 voters showing what Democrats would do with more power, and making clear that we’re moving toward ‘Medicare for all’ as a big part of a 2020 electoral strategy,” said Adam Green, co-founder of the Progressive Change Campaign Committee, an advocacy group. “It seems pretty clear that the presidential nominee, whoever it is, will support Medicare for all.”

Recent polls have found that slightly more than half of Americans approve of the Affordable Care Act, with many more, across political persuasions, wanting to keep its provisions protecting people with pre-existing health conditions. But polls have also found that many Americans are unhappy with their health care and its costs, particularly drug prices, and both parties in Congress have taken note.

Under the Affordable Care Act, many people of modest means can obtain subsidies covering all of their premiums, so the insurance is essentially free. But for those whose income is too high to qualify for subsidies, the costs remain high — a problem that the Trump administration and congressional Republicans have seized on.

Encouraging enrollment under the Affordable Care Act has never been a priority for Trump administration officials, and confusion caused by the court decision in Texas could further depress enrollment, which was already lagging behind last year’s numbers.

From Nov. 1 to Dec. 8, about 4.1 million people had signed up for ACA coverage through the federal marketplace, with new enrollment in the 39 states that use the federal website Healthcare.gov down by 20 percent compared with the same period last year.

In all, 11.8 million people in all 50 states signed up for health insurance through the law’s marketplaces for 2018. This year’s enrollment period is now ending except for in Rhode Island, where it will end Dec. 23, and in California, Colorado, Massachusetts, Minnesota, New York and the District of Columbia, where it will end in January.

“During a year when most people don’t know when the deadline is, if the only news you hear is that the ACA was struck down, that is only going to hurt enrollment,” Josh Peck, co-founder of Get America Covered and former chief marketing officer for Healthcare.gov during the Obama administration, said in an email.

The administration has slashed marketing efforts and enrollment assistance and encouraged people to buy skimpier, less expensive plans that do not meet the standards of the law. These actions, and the elimination of the law’s tax penalty for not having coverage starting in 2019, are most likely among the reasons fewer people are signing up.

Even as enrollment in private plans under the Affordable Care Act will most likely be smaller next year, hundreds of thousands more low-income adults are expected to enroll in expanded Medicaid in five states that recently gave them the option through citizens’ initiatives or legislative action. Those states are Idaho, Maine, Nebraska, Utah and Virginia. Last month’s Kaiser tracking poll found that 59 percent of respondents living in the 14 states that have not yet expanded Medicaid want them to do so.

Other broadly popular provisions of the law are one that allows young people to stay on their parents’ health insurance plan until they turn 26, and another that allows people to get certain types of preventive care, such as vaccinations, mammograms and other types of screenings for diseases, at no charge.

This article originally appeared in <a href="https://www.nytimes.com/2018/12/15/us/politics/obamacare-ruling-health-care.html" id="c20a13d8-134a-3578-a24c-b8231943a11a">The New York Times</a>.

Democrats Warn of '5-Alarm Fire' Over Health Law

WASHINGTON — The decision by a federal judge in Texas to strike down all of the Affordable Care Act has thrust the volatile debate over health care onto center stage in a newly divided capital, imperiling the insurance coverage of millions of Americans while delivering a possible policy opening to Democrats.

Republicans were by and large muted in their response, but incoming House Minority Leader Kevin McCarthy of California appealed to Democrats to come to negotiate a successor to what he called “an unconstitutional law.”

But the ruling is just the latest chapter in the tumultuous history of a law that has transformed life for millions of Americans since the measure was passed without any Republican votes and signed in March 2010 by President Barack Obama.

“While the 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,” said Rep. Greg Walden, R-Ore., departing chairman of the Energy and Commerce Committee.

Sen. Bill Cassidy, R-La., said the court ruling showed the need for a bill such as one he introduced in 2017 with Sen. Susan Collins, R-Maine, who is facing re-election in 2020. The bill would keep consumer protections from the Affordable Care Act but give states much more discretion over the use of federal funds for health care.

But others were taking a wait-and-see attitude. Rep. Tom Cole, R-Okla., said Saturday that he and his colleagues would wait until they saw the outcome of the lawsuit before reacting.

From Nov. 1 to Dec. 8, about 4.1 million people had signed up for coverage through the federal marketplace, with new enrollment in the 39 states that use the federal website Healthcare.gov is down by 20 percent compared with the same period last year.

The ruling, if it stands, would not only do away with coverage protections for people with pre-existing health conditions but would also strike down mandated coverage for what the law deems “essential health benefits,” including emergency services, maternity and newborn care, mental health and substance abuse treatment, prescription drugs and pediatric care.

Republicans were muted in their response, but incoming House Minority Leader Kevin McCarthy of California appealed to Democrats to come to negotiate a successor to what he called “an unconstitutional law.”

But President Donald Trump was in a celebratory mood, tweeting, “Wow, but not surprisingly, Obamacare was just ruled UNCONSTITUTIONAL by a highly respected judge in Texas. Great news for America!”

But others were taking a wait-and-see attitude. Rep. Tom Cole, R-Okla., said Saturday that he and his colleagues would wait until they saw the outcome of the lawsuit before reacting, and dismissed the notion that the ruling would be a political boon for Democrats.

“They think they can whip people up over the health care issue; it worked well for them in the midterms,” Cole said. “But we are two years away from the election, and I think very seldom does something happen in this time frame that has lasting political impact.”

From Nov. 1 to Dec. 8, about 4.1 million people had signed up for coverage through the federal marketplace. Since Nov. 1, new enrollment in the 39 states that use the federal website Healthcare.gov is down by 20 percent compared with the same period last year.

Democrats See 'Five-Alarm Fire' Over Health Law After Judge's Ruling

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Sheryl Gay Stolberg, Robert Pear and Abby Goodnough

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Democrats Warn of '5-Alarm Fire' Over Health Law

Democrats Warn of '5-Alarm Fire' Over Health Law

Democrats See 'Five-Alarm Fire' Over Health Law After Judge's Ruling

Democrats See 'Five-Alarm Fire' Over Health Law After Judge's Ruling