By Rose Hoban

As he drove from one town to the next late last week, Mark Van Arnam was dismayed to hear the news that a judge sitting on a district circuit court in Texas ruled that the entire Affordable Care Act was unconstitutional.

Van Arnam leads the North Carolina Navigator Consortium, a group dedicated to getting as many people as possible signed up for insurance under the Affordable Care Act. The enrollment period for coverage ended on Saturday evening, just as Van Arnam and his troops were in the midst of the final push for enrollment.

This year’s signups have lagged prior years’ counts when North Carolina had some of the strongest enrollment in the country, but the ongoing tallies don’t take into account people who decide allow their coverage to roll over from one year to the next and who don’t get counted until the end.

He said people coming in for appointments to enroll were confused by the news of the ruling.

“When you hear about it on TV, they’re talking about, you know, the big headline which is that a federal court judge strikes down the ACA,” Van Arnam said. “They don’t talk about the appeals, and the process that this has to work through before it’s finally decided, which likely will be all of the way to the Supreme Court.”

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The announcement of the ruling made the navigators’ reminder calls to people ahead of their appointments even more urgent.

On Saturday, Mark Van Arnam was sitting at the registration table of an event geared at getting people signed up for health insurance during the final push for this year’s Affordable Care Act enrollment period.

“There was a woman who came in and said, ‘Thank goodness I got the confirmation call from you all this morning because I wasn’t going to come today because I thought the ACA was done after the news reports I heard last night,’” Van Arnam recalled.

‘Outlandish argument’

Van Arnam is correct that the case Texas v Azar is likely to go to the Supreme Court before being finally decided, said Mark Hall, health policy and law professor at Wake Forest University.

Hall explained that the case ruled on Friday was brought by 20 states’ Republican attorneys general and governors who argued that the mandate which required people to buy health insurance was unconstitutional.

The judge in the case ruled that because the individual mandate was “essential” to the law, it could not be separated from the rest of the law and therefore invalidated the entire 2010 statute.

Hall said he found it an “outlandish argument, the idea the entire structure should fall because of one tiny little bubble. Yet that’s the argument the judge agreed with.”

The individual mandate was already rendered toothless last year when Congress passed the tax cut law and it was signed into law by President Donald Trump. Contained in that law was a provision to reduce the penalty for being uninsured to zero.

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Hall said that even without the individual mandate, the rest of the law is otherwise is “perfectly valid.” He also explained that the judge refused to enjoin the law, which means it’s still functional, even as the fate of the ACA plays out in the court system.

Carrying on?

Hall said just the possibility of the ruling being upheld introduces uncertainty to the insurance market.

“Just the possibility that this will be upheld will add even more destabilizing uncertainty to the market and make insurers less willing to enter or stay in the market, or will cause them to price their products for more of a profit margin to be sure they aren’t harmed by any sudden change in the law,” he said.

Closer to home, the ruling could derail the growing possibility that members of the General Assembly will act to expand the Medicaid program, which is permitted under the Affordable Care Act.

Legislators could expand the program to add people earning from about 50 percent to about 135 percent of the federal poverty rate (from $10,005 to $27,567 per year for a three-person family) If so, it could provide access to insurance for hundreds of thousands of North Carolinians who have fallen into this “coverage gap.” Under the ACA, the federal government would pay for 90 percent of the cost of these new enrollees’ care. For the rest of the state’s Medicaid population, the federal match would remain at about two federal dollars for each spent by North Carolina.

After resisting calls for expansion for years, a group of Republican lawmakers in the House of Representatives has expressed willingness and even some determination to make it happen during the long legislative session that begins early next year.

Rep. Josh Dobson (R-Nebo) was one of the sponsors of a bill introduced last year that would create the Carolina Cares program, allowing for expansion of insurance access to people falling in the coverage gap. The plan would include a work requirement which would have exceptions for people with a medical or financial hardship.

Dobson said he has few concerns about the ruling right now.

“We’re moving forward as if the law was still in place,” Dobson said.

He said the case still has a long way before it’s finally decided, starting with appeals to higher courts which may eventually reach the Supreme Court.

“Five justices on the Supreme Court have already ruled that the law is constitutional,” he said.

“We believe Carolina Cares is good policy and the ACA is still in place, this is a good way to cover the individuals who currently don’t have any way to buy insurance.”

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...