Obamacare faced another critical moment in court. Over 20 million Americans could lose their health insurance if it’s eventually struck down.

Supporters of the Affordable Care Act celebrate after the Supreme Court up held the law in the 6-3 vote at the Supreme Court in Washington June 25, 2015.

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Supporters of the Affordable Care Act celebrate after the Supreme Court up held the law in the 6-3 vote at the Supreme Court in Washington June 25, 2015.
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Reuters/Joshua Roberts

  • The Affordable Care Act, popularly known as Obamacare, has survived two Supreme Court challenges since being signed by President Obama in 2010, but it faced another critical test in a New Orleans federal courtroom on Tuesday.
  • Two of the three judges on the appellate panel were skeptical of the law’s individual mandate, which compels Americans to buy health insurance or pay a tax penalty, Axios reported.
  • If the rest of the law is tossed out, over 20 million Americans could lose their health insurance, according to the Urban Institute.
  • “This is a law touching nearly every aspect of our health care system. It’s hard to imagine how invalidation would work,” Urban Institute fellow Linda Blumberg told INSIDER.
  • Visit the Business Insider homepage for more stories.

The Affordable Care Act, popularly known as Obamacare, has survived two Supreme Court challenges since being signed by President Obama in 2010. But the sprawling health-care law faced another critical test in a New Orleans federal courtroom on Tuesday – and its outcome could upend the lives of millions of Americans who gained health coverage and other protections through the law.

Two of the three judges – both appointed by Republican presidents – on the appellate panel were skeptical of the law’s individual mandate, which compels Americans to buy health insurance or pay a tax penalty, Axios reported. It is possible that they will uphold a lower-court ruling striking down the mandate as unconstitutional without the tax penalty that Congress scrapped when it passed the 2017 GOP tax cuts.

But the same judges are also wrestling with whether to save or strike down in the ACA, which legal experts say is likely to end up before the Supreme Court again.

At the center of the case, Texas v. Aznar, heard in the Fifth Circuit Court of Appeals, was whether the ACA’s mandate requiring most Americans buy health insurance or pay a penalty is constitutional after President Donald Trump signed the 2017 tax overhaul which eliminated the penalty. It came after a federal judge in Texas invalidated the entire law after ruling the individual mandate was unconstitutional without the tax penalty back in December.

Eighteen Republican-led states brought the case forward against the federal government, arguing that revoking the individual mandate renders the entire law unconstitutional. The Trump administration endorsed the plaintiffs earlier this year, leaving it up to 20 Democratic-led states to defend the ACA in court.

If the rest of the law is thrown out, over 20 million Americans could lose their health insurance, according to the Urban Institute. The law’s protections would be gone, including helping to ensure coverage for people with preexisting conditions. Also gone would be the tax subsidies that make coverage more affordable and its protections for young adults to stay on their parent’s plans until they turn 26.

Invalidating the law would likely increase costs for millions of Medicare beneficiaries and the coverage that 12 million people received under the expansion of Medicaid in 37 states, two ways that underscore the ACA’s sweeping changes to American healthcare.

“The impact would be enormous,” Urban Institute fellow Linda Blumberg told INSIDER of the ACA being scrapped. “This is a law touching nearly every aspect of our health care system. It’s hard to imagine how invalidation would work.”

Read more: Trump is picking a risky fight with Democrats over Obamacare

Conservative economist Douglas Holtz-Eakin echoed that, telling Bloomberg News that undoing the law would cause “a thermonuclear meltdown on the health policy front.”

Democrats readily criticized the Trump administration’s efforts to overturn the law. Sen. Chris Murphy tweeted, “There is no way that the Trump administration and Congressional Republicans can pick back up the pieces if this lawsuit is successful.”

Read more: The Trump administration says it supports striking down the entire Affordable Care Act

The ACA has survived attempts by President Donald Trump to repeal it, which Republican lawmakers have attempted to do for nearly a decade. The GOP came close in 2017, but they couldn’t overcome the late Sen. John McCain’s opposition and he cast the decisive vote with a thumbs-down.

During an ABC News interview in June, Trump said he would announce another “phenomenal” health care plan, but many Republicans are hoping he avoids giving Democrats an easy target going into 2020, The New York Times reported last month.

Should the law once again end up before the Supreme Court next year, the ACA’s fate would be decided in the midst of a presidential campaign. And it would presents Democrats with an opportunity to run on protecting the law’s popular provisions – a successful part of their political strategy that helped them recapture the House in the 2018 midterms.

“It is Trump’s nightmare, that at the height of the 2020 campaign he could be in the Supreme Court trying to overturn protections for people with preexisting conditions,” Democratic consultant Jesse Ferguson told CNN. “I think people underestimate what this could all mean.”