Oak Street faces DOJ inquiry into third-party marketing, transportation relationships

Dive Brief:

  • Oak Street Health, a value-based primary care network for adults on Medicare, is facing a Department of Justice inquiry into its relationships with third-party marketing agents and its provision of free transportation for members.
  • The DOJ is investigating whether Oak Street violated the False Claims Act, per a regulatory filing published Monday. On a call with investors Tuesday, management declined to provide additional information into the government’s request, saying it was too early to know for sure what exactly the agency is investigating but that they’re working to comply.
  • Otherwise, the provider had a generally solid third quarter with better-than-expected revenue and well-controlled medical costs, analysts said. Oak Street increased its full-year 2021 guidance following the results, which beat Wall Street expectations with topline revenue of $389 million, up 78% year over year and a quarterly record for the company.

Dive Insight:

The federal government is increasingly cracking down on alleged fraud, especially in the Medicare Advantage program. In privately run MA plans, CMS pays companies on a per-member basis, then adjusts payments based on the acuity or severity of their member’s health status, as supported by provider data like diagnostic codes. Generally, the sicker the member, the higher the plan’s reimbursement.

That’s led to allegations of plans hiking risk scores to overinflate members’ health needs, resulting in higher payments from CMS. Watchdogs have been finding higher incidence of fraud and abuse as the MA program becomes more popular, growing to cover more than 40% of all Medicare beneficiaries.

Oak Street isn’t a traditional plan itself, but enters into full-risk contracts with Medicare Advantage plans, and via CMS’ direct contracting program, in which it assumes full responsibility for patients’ medical expenses in exchange for a fixed per-member, per-month payment. The Chicago-based company is the latest target of a federal inquiry into whether it violated the False Claims Act.

According to the primary care company, the DOJ sent a civil investigative demand on Nov. 1 asking for information about Oak Street’s relationships with third-party marketers and transportation partners.

Oak Street does provide patients transportation to appointments when they need it and has various ways for finding new patients, including community partnerships, but it’s unclear what the DOJ is specifically investigating, CEO Mike Pykosz told investors.

“We have had no meaningful conversations with the government,” Pykosz said. “I’m not really sure what the link is.”

The CEO noted it’s not unusual for such inquiries to take months to resolve, particularly in the hyper-regulated healthcare industry, but said he wouldn’t speculate further.

A civil investigative demand is a form of administrative subpoena, and doesn’t denote any regulatory or legal action itself. However, it is used by the government to kick off investigating potential False Claims violations, and determine whether there’s sufficient evidence to warrant filing an action, according to the National Law Review.

Penalties for violating the act could range from $11,655 to $23,331 per violation, plus triple damages. Total penalties have resulted recently in some significant payouts from MA participants. Notably, in late August, integrated health system Sutter Health agreed to pay $90 million to settle whistleblower allegations of risk adjustment fraud, in the largest False Claims Act settlement against a hospital system in the MA program.

Analysts noted the inquiry, while in early stages, is a point of concern for Oak Street’s future stock performance.

“This creates a new potential risk factor that we are unlikely to get clarity on for some time,” SVB Leerink analyst Whit Mayo wrote in a note.

Oak Street, which also provides services to patients with a range of insurance options, had an otherwise solid quarter, eclipsing $1 billion of year-to-date revenue for the first time in the company’s history.

The highly infectious delta variant did contribute to higher expenses, as it has with other providers.

Oak Street reported $15 million in costs from COVID-19 admissions in the first half of the year, and another $10 million in the third quarter. COVID-19-related expenses surged in the latter half of August and continued into September, but tailed off early into the fourth quarter, CFO Tim Cook said.

The majority of Oak Street’s patients are in northern U.S. markets, however, which experienced coronavirus surges last year during the winter as more people stayed indoors.

“We will see what happens in November and December,” Cook said. “While COVID costs are going to be lower in Q4, unfortunately we’re not in a world where they’re going to be zero.”

In the quarter, the primary care provider’s medical claims expense doubled year over year to almost $310 million. Oak Street’s medical loss ratio of 82.2% was lower than analysts expected, though management said they expected it to be higher in the fourth quarter.

Pykosz and Cook called out medical costs from new patients brought in during 2021 as a system-wide stressor.

Because diagnoses from 2020 claims are used to determine 2021 risk scores, fewer claims last year could mean lower risk scores and lower payments for plans this year. Oak Street’s patients, especially older adults in low-income communities, used fewer services last year during COVID-19, which resulted in lower revenues this year even as costs expanded.

Management said they expected to get back on track in 2022 as patients new to Oak Street this year will contribute to higher reimbursement next year, closing the current medical-cost gap between tenured and new patients.

“This is certainly an outlier year from every other year we’ve had results,” Pykosz said.

Oak Street, which was founded in 2012 and went public in August 2020 at a $9 billion valuation, reported a net loss of almost $110 million in the quarter, compared to a loss of $59 million at the same time last year.

Oak Street continued expanding its membership and network in the quarter, reporting 69% at-risk patient growth and opening 15 new centers in seven new markets.

Oak Street’s competition in the value-based primary care space has ramped up this year, as peers One Medical acquired a rival value-based medical chain and VillageMD got a hefty new investment from drugstore partner Walgreens.

But Pykosz pointed to Oak Street’s exclusive relationship with senior group AARP and its acquisition of specialty telehealth provider RubiconMD as differentiators, while noting there’s room for a number of players in the space.

“At this point we don’t feel there’s a lot of pressure or competitive dynamics pressuring our performance,” Pykosz said.

In the third quarter, Oak Street served 100,500 risk-based patients, representing 76% of its total patient base. The company expects at-risk patient volume to grow to between 111,500 and 113,500 patients this year.

If Economists Chose the Health Care System

If Economists Chose the Health Care System - YouTube

Health economists study the economic determinants of health. They also analyze how health care resources are utilized and allocated, and how health care policies and quality of care can be improved. In this episode, we discuss what exactly a healthcare system would look like if these professionals were calling all the shots.

An epic ACA trilogy draws to a close

https://mailchi.mp/bade80e9bbb7/the-weekly-gist-june-18-2021?e=d1e747d2d8

Supreme Court dismisses challenge to Affordable Care Act, leaving it in  place | News | albanyherald.com
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Ruling by a decisive 7-2 margin, in what dissenting Justice Samuel Alito described as the third in “our epic Affordable Care Act trilogy”, the Supreme Court rejected the latest—and likely the last—effort to overturn the 2010 health reform law. Holding that the states and individuals that brought the latest challenge to the law did not have “standing”—the legal right to sue—the high court effectively closed the book on a decade-long series of challenges to the Affordable Care Act (ACA). Those efforts have included two previous Supreme Court cases, numerous promises to “repeal and replace” Obamacare, and the neutering of the law’s “individual mandate” to buy health insurance, which led to this latest case, Texas v. California.

At issue in the case was whether, by zeroing out the penalty for not purchasing insurance, Congress effectively removed the ACA’s status as a taxation measure, which the Court had previously held as central to the constitutionality of the law. In Alito’s dissenting opinion, the full implications of the issue are laid out: in his view, by invalidating the mandate, Congress rendered the entire law unconstitutional, meaning that it should be overturned. But a majority of seven Justices, including Kavanaugh and Barrett (both appointed by President Trump) disagreed, joining Justice Breyer in his opinion that no harm had been done to the states that brought the suit, and ordering that the case be returned to the lower court for dismissal.
 
More than ten years after the passage of the ACA, it now (finally) seems as though the law is here to stay. Bolstering its central provisions—subsidized individual insurance coverage, expanded Medicaid benefits, protections for those who purchase insurance—is a centerpiece of the Biden administration’s policy program, featured first in the American Rescue Plan Act, and now in the recovery legislation currently being debated. Republicans, who had long opposed the ACA, barely mentioned it during the last presidential campaign, instead turning their focus to thwarting Democrats’ plans to expand coverage by lowering the Medicare eligibility age or implementing a government-run “public option”.

Given the evenly split makeup of the Senate, however, we continue to believe the greatest hurdle such proposals will face is not Republican opposition, but reluctance on the part of conservative Democrats, like Sen. Joe Manchin (WV), whose votes will be needed for any legislation to pass.

With the Supreme Court calling a third strike against challenges to the ACA, and the new administration eager to advance its other priorities (infrastructure, childcare, jobs), for the first time in over a decade, we might just be in for a period of relative calm on the healthcare policy front.

Five takeaways on the Supreme Court’s Obamacare decision

Obamacare Returns as Galvanizing Issue After Ginsburg Death and Barrett  Nomination - The New York Times

In what has become something of a Washington tradition, the Supreme Court again upheld the Affordable Care Act on Thursday, in the third major case from Republican challengers to reach the high court. 

The margin this time was larger, 7-2, as the High Court appears less and less interested in revisiting the health care law through the judiciary. 

Democrats hailed the ruling as a boost to their signature law, and Republicans were left to figure out a path forward on health care amid another defeat. 

Here are five takeaways:

This could be the last gasp of repeal efforts

It is impossible to ever fully rule out another lawsuit challenging the health law or another repeal push if Republicans win back Congress. 

But after more than 10 years of fighting the Affordable Care Act, GOP efforts at fighting the law are seriously deflated, as many Republicans themselves acknowledge. 

“It’s been my public view for some time that the Affordable Care Act is largely baked into the health care system in a way that it’s unlikely to change or be eliminated,” said Sen. Roy Blunt (Mo.), a member of Senate GOP leadership. 

Asked if he still wanted to repeal and replace the law, which was the GOP rallying cry for years, Sen. Chuck Grassley (R-Iowa) said instead, “I think I want to make sure it works,” before attacking former President Obama’s promises about the law’s benefits. 

Even Sen. Josh Hawley (R-Mo.), who helped bring the lawsuit against the health law as attorney general of Missouri, said Thursday that the Supreme Court had made clear “they’re not going to entertain a constitutional challenge to the ACA.”

Supporters of the law said it is now even more entrenched, despite years of GOP attacks

“The war appears to be over and the Affordable Care Act has won,” said Stan Dorn, senior fellow at the health care advocacy group Families USA. 

Still, not all Republicans are throwing in the towel on at least verbally attacking the law. 

“The ruling does not change the fact that Obamacare failed to meet its promises and is hurting hard-working American families,” said House GOP leaders Kevin McCarthy (Calif.), Steve Scalise (La.) and Elise Stefanik (N.Y.). 

And there is at least one ACA-related lawsuit still working its way through the lower courts. Kelley v. Becerra challenges provisions of the health law around insurance plans covering preventive care including birth control.

The Supreme Court was fairly united 

The margin of victory for the health law was fairly large, with even more conservative justices such as Clarence ThomasAmy Coney BarrettBrett Kavanaugh and John Roberts ruling to uphold the law, joining the opinion from liberal Justice Stephen Breyer

The court’s other two liberals, Sonia Sotomayor and Elena Kagan, also joined the majority of seven. Two conservatives, Justices Samuel Alito and Neil Gorsuch, dissented and would have struck down the law. 

Through the three major Supreme Court cases on ObamaCare, the margin of victory has risen from 5-4 to 6-3 to 7-2. 

“There’s a real message there about the Supreme Court’s willingness to tolerate these kinds of lawsuits,” Andy Pincus, a visiting lecturer at Yale Law School, said of the growing margin of victory. 

The case was decided on fairly technical grounds. The Court ruled that the challengers did not have standing to sue, given that the penalty for not having health insurance at the center of the case had been reduced to zero, so it was not causing any actual harm that could be the basis for a lawsuit. 

Republicans did get some vindication in that Democrats had fiercely attacked Barrett during her confirmation hearings for being a vote to overturn the health law, when in fact she ended up voting to maintain the law. 

The ACA is stabilizing

The early years of the Affordable Care Act were marked with the turbulence of a website that failed at launch, premium increases, and major insurers dropping out of the markets given financial losses. 

Now, though, the markets are far more stable. For example, 78 percent of ACA enrollees now have the choice of three or more insurers, up from 57 percent in 2017, according to the Kaiser Family Foundation. 

Democrats, now in control of the House, Senate and White House, were able to pass earlier this year expansions of the law’s financial assistance to help further bring down premium costs. 

The Biden administration announced earlier this month that a record 31 million people were covered under the ACA, including both the private insurance marketplaces and the expansion of Medicaid. 

“We are no longer in the Affordable Care Act, ‘How’s it going to go? Is it going to survive?’ mode,” said Frederick Isasi, executive director of Families USA. “We really are in a whole new phase. It really is: ‘How do we improve it?’”

Republicans face questions on their health care message

The Republican health care message for years was summed up with the simple slogan “repeal and replace.

But now those efforts have failed in Congress, in 2017, and have failed for a third time in the courts. 

That leaves uncertainty about what the Republican health care message is. The party has famously struggled to unite around an alternative to the ACA, so there is no consensus alternative for the party to turn to. 

The statement from McCarthy, Scalise, and Stefanik calling the ACA “failed,” shows that party leaders are not fully ready to accept the law.

The leaders added that “House Republicans are committed to actually lowering health care costs,” which has been a possible area for the party to focus that is not simply about repealing the ACA. 

But any discussion of health care costs is fraught with complications. Republicans, for example, overwhelmingly oppose House Democrats’ legislation to allow the government to negotiate lower drug prices, arguing it would harm innovation from the pharmaceutical industry. 

Grassley reached a bipartisan deal on somewhat less sweeping drug pricing legislation with Sen. Ron Wyden (D-Ore.) in 2019, but that bill went too far for many Republicans as well. 

Democrats want to go farther, but face an uphill climb

With the ACA further entrenched, and control of the House, Senate and White House, Democrats are looking at ways to build on the health law. 

The main health care proposal from the presidential campaign, a government-run “public option” for health insurance, has faded from the conversation and is not expected to be a part of a major legislative package on infrastructure and other priorities Democrats are pushing for this year. 

While the health care industry has largely made its peace with the ACA, pushing for a public option or lowering health care costs means taking on a fight with powerful industry groups. 

Progressives like Sen. Bernie Sanders (I-Vt.) have instead poured their energy into expanding Medicare benefits to include dental, vision, and hearing coverage, and lowering the eligibility age to 60. 

Allowing the government to negotiate lower drug prices also could make it into the package.

“Now, we’re going to try to make it bigger and better — establish, once and for all, affordable health care as a basic right of every American citizen,” said Senate Majority Leader Charles Schumer (N.Y.). “What a day.”

Supreme Court upholds ACA in 7-2 decision, leaving intact landmark US health law during pandemic

The Supreme Court on Thursday issued an opinion upholding the Affordable Care Act by a 7-2 vote, allowing millions to keep their insurance coverage amid the coronavirus pandemic.

In the decision, the court reversed a lower court ruling finding the individual mandate unconstitutional. However, the court did not get to the key question of whether the individual mandate is severable from the rest of the law. Instead, the court held the plaintiffs do not have standing in the case, or a legal right to bring the suit.

Justice Stephen Breyer wrote the opinion while Justices Samuel Alito and Neil Gorsuch filed dissenting opinions.

Breyer wrote that a court must address a plaintiffs’ injuries. But Breyer found there were no injuries, so he asked: “What is that relief? The plaintiffs did not obtain damages.” Breyer added, “There is no one, and nothing, to enjoin.”

A wide swath of industry cheered Thursday’s news.

The American Medical Association called it a victory for patients, so too did America’s Essential Hospitals, a safety net trade group that called it a win. The American Hospital Association said the more than 30 million of Americans who obtained coverage from the law can “breathe a sigh of relief.”

Millions of Americans gained health insurance coverage as a result of the Affordable Care Act, President Barack Obama’s landmark law passed in 2010 and reshaped virtually every corner of American healthcare. The latest challenge threatened to undo coverage gains under the law that helped drive down the uninsured rate to a record low.

Proponents feared the law was in greater jeopardy following the death of Supreme Court Justice Ruth Bader Ginsburg, part of the court’s liberal wing, which shrunk to just three of a total of nine justices without her.

Those fears now seem to be overblown. Chief Justice John Roberts joined the courts liberals in upholding the law, as did two of President Donald Trump’s Supreme Court picks, Justices Brett Kavanaugh and Amy Coney Barrett.

In a rare move, Trump’s DOJ declined to defend the ACA, when the challenge was brought by a group of red states and two men with marketplace plans. Former California Attorney General Xavier Becerra, now HHS secretary, led a group of blue states to defend the law in federal court. 

Recap of the controversial case

The case centers on the individual mandate, the part of the law that compelled Americans to purchase health insurance or pay a fee. The framers of the ACA believed the mandate would help drive healthy people to ensure they weren’t just filled with sick people, risking higher costs and adverse selection for insurers.

Congress effectively killed the mandate in 2017 by setting the penalty to $0.

The plaintiffs’ legal argument was strategic. They directly targeted the linchpin that saved the law in 2012. The Supreme Court largely upheld the ACA in 2012 when it ruled the mandate could be considered a tax and therefore was constitutional. Roberts infuriated conservatives by siding with liberals in that case.

Take that penalty away, by zeroing it out, and the plaintiffs argue the law is no longer constitutional because it can no longer be considered a tax if no money is collected

The key question before the Supreme Court was whether they could simply pluck the individual mandate from the remainder of the monumental health law, throw the entire law out or find some middle ground. 

The plaintiffs have argued that the individual mandate is so intertwined and closely linked to the rest of the law that the entire piece of legislation must fall if the individual mandate is ruled unconstitutional.

Before arriving at the Supreme Courta lower court ruled in 2019 the mandate was unconstitutional but sent back the key question of whether the mandate could be extracted from the remainder of the law back to the district court. The federal appeals court ruling by a three-judge panel came down along party lines: two Republicans and one Democrat.     

A question of standing

Some legal experts have criticized the challenge because the individual plaintiffs, two Texas men, no longer face any financial penalty if they were to forgo coverage. SCOTUS’ ruling agrees with that logic.

The two men joined the case originally brought by a group of red states. Legal experts said it would have been harder for the group of red states to prove an injury than the two men, John Nantz and Neill Hurley.    

The court seemed skeptical of whether the plaintiffs had standing to bring the case during oral arguments in November. Justices spent a large portion of the two-hour hearing on the topic. 

The word standing was mentioned at least 59 times, according to the court’s transcript of the hearing, outnumbering other key words such as severability, another important legal concept in the case. 

In one now-telling exchange from oral arguments, Gorsuch seemed confused over the premise of the challenge to begin with: “I guess I’m a little unclear who exactly they want me to enjoin and what exactly do they want me to enjoin them from doing?”

Supreme Court upholds Affordable Care Act

https://www.healthcarefinancenews.com/news/supreme-court-upholds-affordable-care-act

The Supreme Court has upheld the constitutionality of the Affordable Care Act in a decision released this morning. 

The Republican state plaintiffs, led by Texas, have failed to show they have standing to attack as unconstitutional the ACA’s minimum essential coverage provision, the justices said. 

“Therefore, we reverse the Fifth Circuit’s judgment in respect to standing, vacate the judgment, and remand the case with instructions to dismiss,” they said.

Justice Stephen Breyer delivered the majority opinion, in which Chief Justice John Roberts and Justices Clarence Thomas, Sonia Sotomayor, Elena Kagan, Brett Kavanaugh and Amy Coney Barrett joined. 

Justice Samuel Alito filed the dissenting opinion in which Judge Neil Gorsuch joined. 

Supreme Court’s ACA ruling looms

Some States Make Obamacare Backup Plans, As Supreme Court Decision Looms :  Shots - Health News : NPR

The U.S. Supreme Court is heading into the last month of its current term with one major healthcare case, the move to invalidate the ACA, yet to be decided, The New York Times reported June 1. 

A coalition of Republican-leaning states, led by Texas, have asked the court to strike down the ACA, signed into law in 2010. The states argue that the entire ACA is invalid because, in December 2017, Congress eliminated the law’s tax penalty for failing to purchase health insurance. The states argue that the individual mandate requiring Americans to gain health insurance or pay a penalty is inseparable from the rest of the law and became unconstitutional when the tax penalty was eliminated.

The Supreme Court heard oral arguments in the case in November, and at least five Supreme Court justices indicated support for not striking down the entire ACA.

The court is expected to rule on the matter before its nine-month term ends at the end of June, Reuters reported. 

The risky politics of reopening the ACA debate

https://www.axios.com/newsletters/axios-vitals-67f21192-7818-4d03-9c4c-5c2e3a7b4091.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The sudden threat to the ACA is risky for Republicans in 2020 election -  Axios

The sudden uncertainty surrounding the future of the Affordable Care Act could be an enormous political liability for Republicans in key states come November.

Between the lines: Millions of people in crucial presidential and Senate battlegrounds would lose their health care coverage if the Supreme Court strikes down the law, as the Trump administration is urging it to.

The chart above shows the number of people enrolled in the ACA’s insurance marketplaces or covered through its Medicaid expansion.

  • These options have become especially important over the last six months, as millions of Americans lost their jobs — and thus their employer insurance — due to the pandemic.
  • And more than a quarter of non-elderly Americans have a pre-existing condition that insurers in the individual market could refuse to cover without the ACA, per the Kaiser Family Foundation.

The big picture: Republicans paid a steep electoral price for trying to repeal parts of the ACA in 2017. Republicans’ lawsuit against the health care law, if it succeeds, would boot even more people off of their coverage and undo even more of the ACA’s regulations.

What to watch: Several vulnerable Republicans, including Sens. Susan Collins, Martha McSally, and Cory Gardner, represent purple states that expanded Medicaid and would therefore see steep coverage losses. And the broader fight over the Supreme Court has made it impossible to ignore those stakes.

  • “With the Court setting Nov. 10 as the date for hearing California v. Texas, Republicans caught a break not having it front and center right before the election.  Now it is very much front and center,” said Rodney Whitlock, a former health aide for Sen. Chuck Grassley.
  • “Debates over protection of pre-existing conditions have generally not gone positively for Republicans in purple states/district,” he added.

 

 

 

 

This Legal Attack on the ACA Could Be the Big One

This Legal Attack on the ACA Could Be the Big One

The flag-draped casket of Justice Ruth Bader Ginsburg lies in repose under the Portico at the top of the front steps of the US Supreme Court. Ginsburg died at 87 on September 18 after serving on the high court for 27 years. 

When news broke of Justice Ruth Bader Ginsburg’s death on September 18, the outpouring of grief and gratitude for the accomplishments of the feminist icon was quickly followed by speculation over how her passing will affect the legal challenge to the Affordable Care Act (ACA) now before the US Supreme Court.

The landmark health law survived high court rulings in 2012 and again in 2015. In each case, Chief Justice John Roberts voted with the court’s liberal bloc, including Ginsburg, to uphold the ACA. President Donald Trump has nominated conservative Judge Amy Coney Barrett of the Seventh Circuit of the US Court of Appeals to fill Ginsburg’s seat. Because oral arguments for California v. Texas are set for one week after Election Day, supporters of the law are uneasy.

“If the suit had a trivial chance of success yesterday, it has a new lease on life,” University of Michigan law professor Nicholas Bagley told Amy Goldstein in the Washington Post after learning of Ginsburg’s death. “The ACA has become part of the basic plumbing of the US health care system. Ripping it out at this point would create enormous problems.”

If the ACA is overturned, the consequences could be severe. At this point, the nation remains mired in the coronavirus pandemic, which has metastasized into one of the greatest public health crises in a century. Last week, the US reached the horrific milestones of more than 7 million people infected and 200,000 dead from COVID-19. ACA protections for people with preexisting conditions would disappear if the health law is struck down, and more than 12 million adults who have gained health coverage through the ACA’s Medicaid expansion could lose it. More than 9 million others would lose access to subsidized premiums for private health insurance.

Still, the worst-case scenario is just one of many. Here is a review of the lawsuit, what’s at stake, and the potential outcomes.

Implications of Eliminating the Individual Mandate

California v. Texas originated from a consortium of Republican state attorneys general led by Texas. A California-led coalition of 20 states and Washington, DC, is defending the ACA. The Texas coalition argues that the ACA is unconstitutional in its entirety because Congress in 2017 zeroed out one provision of the lengthy law, the individual mandate. If that part of the ACA is invalid, they argue, then the rest is too.

Many legal experts find this position unpersuasive. The arguments “have been roundly criticized by conservative legal scholars, the Wall Street Journal editorial board, the National Review editorial board, health care stakeholders, and some Republican members of Congress and state officials,” ACA expert Katie Keith, JD, MPH, wrote on the Health Affairs Blog. The Supreme Court is scheduled to hear oral arguments in the case on November 10, one week after the election.

Threats to the Vulnerable

Thanks to the 10-year-old ACA, millions of Americans have gained health coverage. This has proved to be essential during the global pandemic. But if the health law is struck down, about 21 million people who buy health insurance through the ACA exchanges or who gained coverage through Medicaid expansion would be at serious risk of becoming uninsured.

California enthusiastically leaned into the ACA from the start and saw the biggest decline in uninsured residents — 3.7 million — of any state. As the California uninsured rate fell, racial disparities in coverage were also reduced. By 2016, the ACA had produced historic declines in racial disparities in health coverage rates for Californians. (Learn more about the impact of the ACA in California with this collection of resources.)

Nationwide, nearly 133 million people with preexisting conditions could be denied coverage or be required to pay more for a health insurance policy if the ACA is eliminated.Contracting the [coronavirus] is the ultimate preexisting condition,” Andy Slavitt, former administrator of the Centers for Medicare & Medicaid Services under President Barack Obama, and Bagley wrote in the New York Times. “The disease can bring with it mysterious complications and affect virtually every organ system, the immune system, and even the limbs. Young, otherwise healthy people may find themselves uninsurable if the Affordable Care Act is struck down.”

A lawsuit that once seemed like a long shot now has a much more reasonable chance at success — and that means 20 million people’s health coverage really could be in the balance.

—Sam Baker, Axios

Also at risk are essential health benefits that the ACA requires all health plans to cover, including maternity care, mental health services, and substance use disorder treatment. If the law is overturned, they could disappear from insurance plans.

“Other popular provisions hang in the balance, including those that guarantee preventive care with no out-of-pocket payments; end lifetime caps; allow kids to stay on their parents’ insurance through age 26; and make vaccines free to patients. Even some key improvements to Medicare — including a reduction in prescription drug costs for beneficiaries — would be gone,” Slavitt and Bagley wrote.

The ACA’s impacts reach far beyond health care consumers. “Insurance companies, drug companies, hospitals, and doctors have all changed the way they do business because of incentives and penalties in the health law,” Julie Rovner wrote in Kaiser Health News. “If it’s struck down, many of the ‘rules of the road’ would literally be wiped away, including billing and payment mechanisms.”

Supreme Court Scenarios

If the Republican Senate votes to confirm Barrett before the oral arguments for California v. Texas, the ACA faces a tougher battle, though it could be narrowly upheld. Although Barrett has not participated in any cases regarding the ACA on the Seventh Circuit, “her academic writing and public action offer glimpses into her views” opposing the health law, Goldstein and Alice Crites reported in the Washington Post.

If Barrett misses the oral arguments, she will not participate in the case. The Supreme Court could choose to postpone the arguments or proceed with eight justices, which is “far from unprecedented,” Keith wrote. Should that result in a 4-4 ruling, the lower court’s decision would stand, and the case would be remanded to a federal district court judge to decide which other provisions of the law must fall along with the individual mandate. Other provisions on the chopping block “could include the law’s rules banning insurers from denying people coverage or charging them higher premiums because of their medical history,” Dylan Scott wrote in Vox. Litigation could continue for years, during which the ACA would remain the law of the land, according to Keith.

This is not an exhaustive list of potential outcomes. For example, an eight-judge court could narrowly rule in favor of the ACA.

As Sam Baker wrote in Axios, “A lawsuit that once seemed like a long shot now has a much more reasonable chance at success — and that means 20 million people’s health coverage really could be in the balance.”