Much at Stake for States Defending the ACA in Texas v. United States

Over the past year, 21 Democratic attorneys general and House Democrats have stepped in to defend the Affordable Care Act (ACA) in the case of Texas v. United States, the dark-horse lawsuit supported by the Trump administration’s Department of Justice that threatens to dismantle the entire law. (Read our previous blog recapping the dangers of this lawsuit here.) However, on June 26, the Fifth Circuit Court of Appeals questioned whether or not the Democratic attorneys general and House have standing to intervene because the Trump administration, as the primary party, has declined to defend the case. If the Court decides that the Democratic defendants do not have standing, the Court could also decide to leave the district court decision striking down the ACA in place, as well as open up other legal questions.

Yet, as Health Affairs’ blogger Katie Keith notes in her great explainer, the intervening states should have standing to intervene in Texas. The end of the ACA would spell out serious harm for the intervening states and result in more than $650 billion in lost federal health care funds—including $61.1 billion in funding for Covered California and $99.1 billion in Medicaid spending in California alone leading up to 2028. Here’s a deeper dive into the damage that this lawsuit would wreak upon health care in the intervening states.

The number of uninsured people in these states would increase dramatically. According to the Urban Institute, by repealing the Affordable Care Act, the number of uninsured nonelderly would increase by nearly 150 percent in Kentucky. In eight other states, the number of uninsured would increase by over 100 percent, reaching 130 percent in Connecticut and 126 percent in Iowa. In the rest of the intervening states, except for in Hawaii, the number of uninsured would increase between 40 and 96 percent. That adds up to over 10 million more uninsured people across the intervening states.

Millions of people enrolled through Medicaid expansion in these states would lose coverage. Kaiser Family Foundation reports that 17 million people now have coverage through the expanded Medicaid program, including 12.8 million people in the intervening states. That’s thousands and thousands of people in each of these intervening states who could lose their coverage if this lawsuit succeeds, including 3.8 million people in California and 3.5 million people in New York.

These states would lose protections for millions of their residents who have pre-existing conditions. According to the Center for American Progress, over 60 million people in the intervening states have pre-existing conditions. The lawsuit would repeal protections for pre-existing conditions, meaning that those 60 million people would be at risk of losing their coverage or paying higher premiums. In all but three of the intervenor states, more than a million people would face this risk, including over sixteen million people in California, over five million people in Illinois and over four million people in Michigan.

Intervening states would be left with billions of dollars more in uncompensated care, or care provided to those who cannot pay for it. Without the ACA’s key support for rural hospitals, the demand for uncompensated care across the intervening states would increase by $26.5 billion, leaving state and local governments or health care providers to pick up the bill or let people go without the care they need. In eleven of the intervening states (California, Colorado, Illinois, Michigan, Minnesota, New Jersey, New York, North Carolina, Oregon, Virginia and Washington) the statewide demand for uncompensated care would exceed $1 billion, reaching higher than $8 billion in California.

These numbers above also don’t mention the thousands of people in these states with substance use disorders who could lose access to treatment, the many seniors who would have to pay for more prescription drugs, or the thousands of young adults who would be kicked off their parents’ coverage.

The data shows (see Chart 1 below) that these Democratic attorneys general are stepping in for an important reason—to speak up for thousands and millions of people in their states who need and deserve access to health care. These states, like all states across the country, have a lot to lose if this lawsuit succeeds, and as the July 9 date for oral arguments approaches, it’s even more essential that we stand behind the attorneys general defending coverage across the country.

Chart 1:

State fact sheets from Protect Our Care.

Data on increase of uninsured and demand for uncompensated care from the Urban Institute.

Data on the expansion populations from Kaiser Family Foundation.

Data on number of people with pre-existing conditions from Center for American Progress.