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It’s not just that 21 million people would probably lose health insurance, or that 133 million Americans with pre-existing conditions would lose their protection. Those effects would be the major focus of attention if the Affordable Care Act were to be struck down.
But the law was much, much broader, affecting a wide range of health programs, even some areas you might not think of as related to health. Overturning the entire law would mean all of its parts, in theory, would go away at once.
On Tuesday, a federal appeals court heard arguments from 18 Republican-led states and the Justice Department that the law should be invalidated. In some ways, that echoes arguments made to the courts in 2012, before much of the law was first put in. Repealing it then would have been a big deal. But doing so now, after so many of its provisions have unspooled, would be much trickier and more consequential.
During oral arguments, two of the three judges expressed some openness to the argument from the states. Of course, any ruling that invalidated the health law would be appealed to the Supreme Court, where the five justices who voted to uphold it in 2012 remain.
Setting aside the politics of the upheaval, the mechanics are not obvious, and could cause policymakers enormous headaches. Here are some provisions that would be particularly hard to make disappear or untangle from the health system.
Consumer protections for insurance customers
Protections for pre-existing conditions weren’t the only rules for insurers established under Obamacare. Without it, health plans could also begin limiting the total amount of financial protection they offer customers, increasing deductibles, charging higher prices to older customers, and dropping expensive categories of benefits, like prescription drugs.
Authorization for the Indian Health Service
The health law included a permanent legal authorization for the Indian Health Service, which runs hospitals, employs physicians and provides health services to more than two million Native Americans. Repealing the law would invalidate the legal basis for that program.
Biosimilar drugs
The health law enabled the Food and Drug Administration to consider and approve biosimilars, drugs akin to generic versions of biologic drugs, which can’t be copied as precisely as typical drugs. Twenty-one biosimilar medications have been approved by the F.D.A. with the new process. Eliminating the health law could jeopardize those approvals and discourage drugmakers from investing in new biosimilar drugs.
Many Medicare experiments
Under Obamacare, a new office can test strategies for how to pay for health services, a provision meant to improve health care quality and efficiency. Many such experiments have been started by the Center for Medicare and Medicaid Innovation, including programs that pay hospitals a lump sum for joint replacement care and one that pays the Y.M.C.A. for a course that appears to lower diabetes risk.
Some of these programs are small, voluntary pilots. Others have been made permanent and expanded nationwide. The office, its employees and all of these programs would lose their authorization.
Some represent Obama administration priorities, but the Trump administration has begun several of its own innovation center projects, including one that may link Medicare’s payment for certain drugs to prices from an international index, an administration priority.
Other, subtler changes in how Medicare pays for things
The law also changed several Medicare payment formulas, in many cases reducing the amounts paid to hospitals. Those changes have been wound into regulations and are built into the business models of many health care providers, so rolling them back would not be simple. These changes also helped extend the life of the Medicare Hospital Insurance Trust Fund. Without them, Medicare would be likely to lose several years of fiscal solvency.
Restaurant menu labels
The law required chain restaurants to publish calorie counts on their menus. The restaurant industry disliked the rule, and the labels would most likely disappear from many restaurants if the requirement were erased. But the industry has already put considerable resources into adding the calorie information to the menus.
The ‘Sunshine’ law
This provision, a longtime priority of Senator Chuck Grassley of Iowa, requires pharmaceutical companies to disclose gifts and payments to physicians.
Medicare prescription drug discounts
The health law reduced the so-called doughnut hole in Medicare drug plans, a gap in which drug plans don’t pay for patients’ medications once they reach a certain total cost. This would mean increased drug costs for many people using Medicare.
Benefits for breastfeeding mothers
Obamacare included benefits for breastfeeding mothers, including insurance coverage for breast pumps and a requirement that many employers provide a room for mothers to express milk. If Obamacare were invalidated, the thousands of employers who have changed offices and policies could drop those benefits, but would presumably risk complaints from workers.