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The Affordable Care Act Is On Trial Again — This Time In Louisiana


Now let's bring NPR's Selena Simmons-Duffin to explain how today's news fits into this long history of challenges to the Affordable Care Act.

Welcome to the studio, Selena.


CORNISH: So Republicans weren't able to kill the law, but they were able to make the fine for not having insurance $0, right? So what was the thinking there?

SIMMONS-DUFFIN: Well, this goes back to the way Congress wrote the law. The individual mandate was supposed to make everything else in the law work. If you didn't require healthy people to get insurance, there would be this sudden flood of unhealthy people into the insurance pool. And that would make everyone's premiums skyrocket.

CORNISH: So what actually happened once the penalty was changed?

SIMMONS-DUFFIN: Well, we don't actually know. The $0 penalty just went into effect this year, so it's unclear what it means for enrollment or premiums. But there was this more immediate impact, which was that Republicans could claim a political win. And they got a new chance to challenge the law in the courts.

CORNISH: That brings us to today and this case - Texas v. the United States at the 5th Circuit Court of Appeals. Help us understand what's playing out here.

SIMMONS-DUFFIN: So Texas and some other Republican states sued the government and said, hey. The Supreme Court found this whole law revolves around the power to tax. If the tax penalty for not having insurance is now $0, that's not a constitutional tax. And since the individual mandate penalty is central to the whole law, it can't just be broken off. So the whole law is unconstitutional, and it must be struck down. This past December, a federal judge in Texas agreed with that whole argument and struck down the law. California and some other states appealed. And today, a panel of three judges heard oral arguments. Only the two judges appointed by Republican presidents asked questions. And those watching in the courts said it seemed like they might agree with Texas and the other plaintiffs. There's no deadline for them to make a decision. It'll probably take months.

CORNISH: What does any of this mean for coverage right now? Could people lose their health insurance?

SIMMONS-DUFFIN: No, no, no, no. None of this is going to change while this is playing out in the court. The law's not going away. And today, Senate Majority Leader Republican Mitch McConnell said even if the law is struck down later, the millions who have pre-existing conditions would still be covered because Congress would come in and quickly pass a law to restore those protections.

CORNISH: It's surprising to hear people talk like that because let's say the Affordable Care Act is struck down. It's been law for nine years. So could it even be dismantled so easily?

SIMMONS-DUFFIN: It's a huge question. Everything in our health system has been changed by this law. You can get insurance even if you have a pre-existing condition, and 130 million Americans do. You can buy your own insurance in a marketplace. A lot of employers have to offer insurance. Those are, like, the big-ticket items that you know from this law, but then there are a million other little things like - you know how there are calorie counts on menus now? That's an Affordable Care Act part. So we've had nine years of getting used to all of these things, and it's unclear if we could disentangle our current health system from this law. And then the prospect of 20 million people losing coverage is out there too if this law goes away.

CORNISH: What happens next with the case?

SIMMONS-DUFFIN: Well, whatever decision we get from this panel of judges in a few months will almost certainly be appealed by the losing side. And that could mean we're looking at another blockbuster Supreme Court case about the Affordable Care Act. And that's smack dab in the middle of the 2020 presidential campaign.

CORNISH: That's a political high wire act, right? I mean, what does that mean for both parties?

SIMMONS-DUFFIN: Right. So, I mean, we've talked about this law is baked into our health care system, but Americans are still really divided over whether it's a good thing or not. Recent polls from the Kaiser Family Foundation found 80% of Democrats like the law. Eighty percent of Republicans don't like the law. And Republicans like President Trump and those in Congress thinks it's still a winning issue for them. Democrats think that health care got them the House in 2018. So no matter what happens, we are going to be hearing a lot about health care in the upcoming election.

CORNISH: That's NPR's Selena Simmons-Duffin.

Thank you.

SIMMONS-DUFFIN: Thank you. Transcript provided by NPR, Copyright NPR.

Selena Simmons-Duffin reports on health policy for NPR.