• The Trump administration released new rules around the use of Obamacare's state innovation waivers on Monday.
• The Department of Health and Human Services and Centers of Medicare and Medicaid Services argued that the regulations would help states create rules that would drive down costs and provide flexibility for consumers.
• The changes appear to be part of the Trump administration's ongoing campaign to reshape the healthcare system without repealing Obamacare.

The Trump administration on Monday released new rules that could allow states to offer less generous health insurance plans through their Obamacare markets to drive down costs for consumers. But health policy experts warned that the changes could help undermine some of Obamacare's key protections.

The Department of Health and Human Services and Centers for Medicare and Medicare Services issued new guidance on the use of the Affordable Care Act's Section 1332 waivers that would give state governments more flexibility in offering plans that do not comply with the ACA's basic coverage requirements.

According to health policy experts, the guidance would make it easier for states to undermine key parts of Obamacare and weaken protections for sicker Americans.

Since the failure of the GOP's Obamacare repeal and replace efforts in 2017, the waivers have become a key approach in the Trump administration's attempts to roll back parts of the ACA.

"Now, states will have a clearer sense of how they can take the lead on making available more insurance options, within the bounds of the Affordable Care Act, that are fiscally sustainable, private sector-driven, and consumer-friendly," HHS Secretary Alex Azar said in a statement.

Larry Levitt, senior vice president at the nonpartisan Kaiser Family Foundation, said the new waiver guidance is further evidence that the Trump administration is attempting to chip away at the ACA.

"Republicans couldn’t repeal and replace the ACA last year, but this guidance gives states the flexibility to shift the law in much the same way," Levitt told Business Insider via email.

Here's a rundown of some of the key changes in the waiver guidance:

• Preference for private plans: The Obama administration designed the waivers with the intention of states attempting their own version of a public option, or government-provided healthcare plan. The new guidance makes it clear that the Trump administration favors plans that use private insurance plans, rather than public plans like Medicaid buy-in.
• Allows the expanded use of non-ACA compliant plans: Currently, insurance plans offered on the Obamacare exchanges — where people without coverage from a job or a government program like Medicare can get their coverage — must abide by a stringent set of rules. The plans must cover people with preexisting conditions, must charge those people the same rate as healthier people, and cover 10 essential health benefits (basic types of care like prescription drugs and maternity care).
  
  • The new wavier rules would allow states to set up programs that offer plans that don't abide by the ACA rules as long as there is one ACA-compliant option. The non-compliant plans would likely be cheaper, but also would provide fewer protections in the event people enrolled in the plan get sick.
  • Dan Meuse, a health policy expert at Princeton University, tweeted that the guidance "suggests that states will be encouraged to expand plans that don't cover preexisting conditions — even using subsidies to pay for them — as long as one comprehensive plan is offered (regardless of cost)."
• Expand the definition of what counts as coverage: Currently Section 1332 wavier requests must show that the same number of people will be covered when the waiver is implemented as prior to implementation. As it stands now, only people who have a plan that covers the ACA's essentials health benefits (EHBs) count towards that coverage number. The new guidance would expand the definition of who is covered to include people on short-term, limited duration plans that do not cover EHBs as long as they had the chance to buy a compliant plan.
  
  "States would have to project that at least as many people would be covered, but they could be covered under skimpier insurance," Levitt said.
• Would allow people to use subsidies to purchase non-ACA compliant plans: Currently, ACA premium subsidies can only be used on plans that comply with all ACA rules. The new guidance could allow states to let people use subsidies to buy less generous plans like short-term, limited-duration health insurance.
• States can enact a wavier without legislative approval: Previously, any waiver had to be adopted by the state's legislature for the federal government to approve the waiver. Now, in some circumstances an executive order from the governor can be enough.
• Changes the name of the waivers: Previously, Section 1332 waivers were known as "State Innovation Waivers." The Trump administration renamed them "State Relief and Empowerment Waivers."

Only eight Section 1332 waivers have been approved by the federal government, and most have focused on supporting the current Obamacare market through reinsurance programs — rather than offering alternative plans. But Levitt said the new rules could change that.

"It's hard to overstate how much flexibility states will have under the Trump administration's new guidance for ACA waivers," he said. "This will likely widen the gap between red states and blue states for access, affordability, regulation, and protections for pre-existing conditions."

SEE ALSO: Republicans tried to kill Obamacare. Now they're trying to embrace its most popular feature in a defining fight of the midterms.

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• For the first time in a decade, Medicaid enrollment did not grow in 2018.
• According to a new Kaiser Family Foundation report, enrollment fell 0.6% in 2018.
• Medicaid spending continued to rise, increasing 4.2% in 2018, due to a higher number of seniors enrolling.
• The drop in enrollment was due to the strong economy and policy changes made by states.
• Medicaid enrollment could change significantly in the next few years given policy changes such as work requirements and ACA expansion being considered by state governments.

For the first time in a decade, Medicaid enrollment hasn't grown in 2018.

While enrollment into Medicaid, the state and federal program that covers medical care for some low-income Americans, slowed down in 2018, spending continued grew 4.2% compared to 2017, according to a survey conducted by the Kaiser Family Foundation.

KFF attributed the growth in spending to the number of seniors joining the program compared to children and adults, who are less expensive to cover. States told KFF that a stronger economy led to fewer adults qualifying for the program.

Medicaid is designed to help low-income Americans get access to healthcare, though the exact threshold for qualification depends on whether the state expanded Medicaid eligibility under the Affordable Care Act (ACA), also known as Obamacare. In states that expanded Medicaid eligibility, adults who make as much as 138 percent of the poverty level can qualify. In those that didn't, the thresholds are far lower, and the program can mainly serve some disabled individuals and parents and their children.

With unemployment hitting multi-decade lows and wages rising, the number of Americans climbing above those cut-offs more than offset the general population growth and other changes in the composition of Medicaid enrollees. Medicaid enrollment last declined in 2007, according to the survey.

The organization also attributed the growth in spending in part to more outlays for pricey medications like treatments for HIV and hepatitis C, as well as more getting spent on substance-use treatment, mental health, and long-term care for seniors and those with disabilities, as well as policy changes that raised the amount of money doctors and nurses are getting paid.

While the Medicaid enrollment rate remained steady in 2018 and is expected to do so again next year, the authors of Kaiser's study did point to a few political factors that could affect the outlook.

"Looking ahead, economic conditions and the outcome of federal and state elections are likely to have implications for Medicaid policymaking as well as for spending and enrollment trends," the report reads. "Potential federal efforts to further change the ACA or cap Medicaid financing as well as state ballot initiatives and other
state efforts to adopt the Medicaid expansion are key issues to watch."

Currently, three states will vote on Medicaid expansion in the 2018 midterms — Idaho, Utah, and Nebraska — which could help boost enrollment numbers as previously ineligible people in those states could be able to get access to Medicaid. According to estimates, just under 120,000 people could be eligible for Medicaid if Idaho votes for expansion, 86,000 could be eligible in Nebraska, and 158,000 could be eligible in Utah.

But working in the other direction is a slew of new proposals from states that would change eligibility rules for Medicaid, the most notable being the imposition of work requirements. The Trump administration has allowed states to set rules to impose a minimum amount of hours that a Medicaid enrollee must work, or do other activities like volunteering or training.

While most enrollees are either disabled, too old to qualify, or already work, administrative difficulties and other factors are expected to result in enrollment declines for states that do impose work requirements. Arkansas, which imposed a work requirement in June, has already seen enrollment drop by just under 8,500 in just two months.

Indiana and New Hampshire already have waivers approved by the Trump administration to start the requirements in 2019, while four others states — Alabama, Maine, Ohio, and South Dakota —have waivers pending. One state, Kentucky, must resubmit a waiver due to a court order before rolling out its work requirement.

See also: 

• Investors including Andreessen Horowitz just made a $300 million bet that a startup can take on healthcare giants at caring for elderly Americans
• Investors are betting $660 million that companies that ship Viagra and hair loss pills to your door is the future of medicine —but some doctors are worried

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• Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, poked fun at the growing Medicare For All movement in a tweet Wednesday.
• Verma tweeted a picture of a shirt with "MEDICARE FOR ALL" on it with the caption: "This year’s scariest Halloween costume goes to..."
• Medicare for All is becoming an increasingly popular idea among Democratic candidates — and the general public.

Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, took a Halloween shot at the growing Medicare for All push among Democrats.

In a tweet, Verma posted a picture of a person wearing a T-shirt emblazoned with "MEDICARE FOR ALL" across the torso and added: "This year’s scariest Halloween costume goes to..."

The Trump administration, including the president, has recently attacked the idea of Medicare for All, attempting to paint it as a socialist policy that would deprive seniors currently on Medicare of their benefits.

But advocates — most notably Sen. Bernie Sanders, who popularized the idea during the 2016 election — argue that Medicare for All would help to give access to healthcare to all Americans while bringing the US system more in line with the rest of the industrialized world. A recent surge in candidates supporting the idea, and an apparent endorsement from former President Barack Obama, helped to raise its profile in recent months.

Read more: Democrats are embracing a radical change to US healthcare, and it could be the defining political fight for years to come

The concept is also picking up steam with the general public. Recent polling showed anywhere from 59% to 70% of Americans were in support of Medicare for All.

While Medicare for All advocates have been looking to radically overhaul the healthcare system, Verma's department has been working to reshape the current system.

CMS recently issued rules on state waivers and short-term insurance plans that would undermine protections for people with preexisting conditions. CMS is also pushing full speed ahead with waivers that let states impose Medicaid work requirements— measures that lock out low-income Americans from benefits if they do not meet certain employment requirements or are unable to work.

While the debate over Medicare for All is fierce — opponents say it will cost the government too much, supporters say it will actually save the US money overall — this is likely the first time an administration official has used a Twitter joke to weigh in on the debate.

SEE ALSO: Trump called 'Medicare for All' a 'catastrophe' and 'disaster.' Here's what the plan would really do.

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NOW WATCH: Trump once won a lawsuit against the NFL — but the result was an embarrassment

• November 1 marked the opening day for Obamacare marketplace open enrollment.
• The average premium for the benchmark Obamacare plan will decline in 2019 compared to the year before.
• In fact, premiums are falling in 18 states, and another 13 are only seeing increases of 5% or less.
• While President Donald Trump has taken credit for the falling costs, health policy experts point to a different reason for the cost slowdown.

November 1 marked the first day Americans can sign up for health insurance on the Affordable Care Act's marketplaces for 2019, marking the sixth open-enrollment period for the law known as Obamacare and the first to feature a fully stabilized program.

After years of increasing premiums, the marketplaces — for people who do not get coverage from their job or a government program like Medicare — appear to have finally settled into a groove. Many states will see small increases, and some will even experience decreases in premiums.

Why exactly we aren't seeing the sky-high premium increases of previous years is a matter of some political debate, but many experts say that the improving costs are simply a function of time. 

The map

For the 39 states that use the federally facilitated Healthcare.gov platform, open enrollment runs from November 1 until December 15 (other states may have longer enrollment periods).

This is half the length of open enrollment periods under former President Barack Obama. But consumers in most states should be getting some relief from the skyrocketing premiums of recent years. The Kaiser Family Foundation, a nonpartisan health-policy think tank, crunched the numbers on premiums for every state and found a more favorable environment for consumers compared to previous years.

To determine a benchmark for premiums, Kaiser used the second-lowest cost silver-level plan for a 40-year-old male. (While the Department of Health and Human Services uses a 27-year-old male for its benchmark, the actual pool of enrollees is typically a bit older.)

Overall, the United States saw an average premium decrease of 0.83% from 2018 to 2019 plans:

• 19 states posted premiums declines.
• 13 states saw increases of between 0% and 5%.
• For states that use the federal Healthcare.gov platform, the decline will be even better, with premiums dropping 1.5% on average.
• On the other end, there were only six states to post double-digit increases for benchmark premiums: Vermont, North Dakota, Delaware, Washington, Hawaii, and New York. Washington, DC, also posted a 16.13% jump.

The premium increases for 2019 are a far cry from just two years ago, when some states were facing jumps as high as 116% in Arizona. Trump, then a candidate, and the GOP used the premium jumps as an effective weapon against Hillary Clinton and many Democratic candidates.

During that election, Republicans promised to repeal and replace the ACA, a promise they failed to keep. The Trump administration and the GOP have made major changes to the healthcare system, but whether those are the reason for the easing of increases is up for debate.

Why are premiums going down?

Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, took credit for the drop.

"President Trump’s Administration took action to address the skyrocketing price of health insurance, and now we are starting to see the results," Verma said.

The administration took a series of actions to shake up the ACA marketplaces, including the expansion of short-term, limited-duration health plans. In addition, the GOP repealed the individual mandate — the requirement every American have insurance or face a financial penalty — as part of the tax reform law.

While Republicans pointed to those actions as examples of policies that reduced premiums, health-policy analysts have argued they have weakened protections for people with preexisting conditions and could eventually drive up costs for sicker people who remain in the Obamacare markets.

But even in terms of 2019's cost, recent studies showed that premiums are coming down in spite of Trump's changes — not because of them:

• Researchers at the Kaiser Family Foundation went through insurer filings and various data to model just how much the Trump administration's actions influenced premiums and found that the meddling actually made premiums higher than they would have been otherwise.
• The main reason for 2019's premium drop is that profit margins on many insurers' Obamacare products grew after the large price jumps in previous years.
• Those companies could now correct back in the other direction by lowering premiums. 
• But the Trump administration's actions forced the insurers to keep the premiums 16% higher than they would be otherwise, Kaiser said.

"Instead of 2019 benchmark silver premiums on healthcare.gov averaging $495 per month for a 40-year-old, as was recently reported by HHS, we estimate the premium would be approximately $427 in the absence of individual mandate penalty repeal, expansion of more loosely regulated plans, and the loss of cost-sharing subsidy payments," the report said.

Another study by Matthew Fiedler, a fellow at the Brookings Institution, found a smaller potential plunge.

"Indeed, under my base assumptions, I estimate that the nationwide average per member per month premium in the individual market would fall by 4.3% in 2019 in a stable policy environment," Fiedler wrote.

Prices are still much higher than just a few years ago

Breaking down the last five years of premium jumps, the large shifts in cost across the US are obvious:

Since 2014, three states have seen premiums for benchmark plans increase by more than 200% — Nebraska, Oklahoma, and Iowa — while 20 states have seen an increase of at least 100%.

Additionally, only two states have seen premiums go up by only single digits: Indiana (the lowest increase at 3.35%) and New Jersey (8.98%).

SEE ALSO: Republicans tried to kill Obamacare. Now they're trying to embrace its most popular feature in a defining fight of the midterms.

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• The Affordable Care Act, or Obamacare, allows states to expand the Medicaid healthcare program to people making up to 138% of the federal poverty limit.
• Three states have questions on the ballot in Tuesday's midterm elections that would expand Medicaid: Idaho, Nebraska, and Utah.
• Six other states — Florida, Georgia, Kansas, Maine, South Dakota, and Wisconsin — have Democratic candidates for governor on the ballot that would expand Medicaid access.
• According to healthcare consulting firm Avalere, up to 2.7 million people could gain access to coverage on Tuesday.

Tuesday's midterm elections not only will determine the control of Congress and dozens of governors' mansions across the US. It could decide access to healthcare for millions of low-income Americans.

The Affordable Care Act's Medicaid expansion, which allows low income Americans making up to 138% of the federal poverty limit to get access to the program, will be on the ballot in three states. And six other states that have not expanded the program have pro-expansion governor candidates on the ballot, as well.

According to Avalere Health, a healthcare consulting firm, up to 2.7 million Americans could gain access to healthcare if the results break a certain way. In three states — Idaho, Nebraska, and Utah — Medicaid expansion is directly on the ballot, while six other states that have not expanded Medicaid have Democratic, pro-expansion governor candidates in competitive races.

"In states with competitive gubernatorial races, many candidates are making Medicaid expansion a key differentiator," Elizabeth Carpenter, senior vice president at Avalere, said of the possible expansions. "Depending on the election results, we could see Medicaid expansion on the agenda again in states across the country."

Here's a breakdown of how many people could gain access to healthcare in each state if the pro-expansion result comes through:

• Florida (governor race): 1,343,612
• Georgia (governor race): 690,162
• Kansas (governor race): 136,423
• Maine (governor race): 48,382
• South Dakota (governor race): 45,293
• Wisconsin (governor race): 140,774
• Idaho (ballot question): 92,439
• Nebraska (ballot question: 97,937
• Utah (ballot question): 134,756

Medicaid expansion has become more popular over the years, even in deep red states, making it a strong issue for many Democratic candidates. A February poll by the Kaiser Family Foundation, a nonpartisan health policy think tank, found that 56% of people in non-expansion states wanted to expand Medicaid, while just 37% were against it.

Another poll in October from Kaiser found that 49% of people said they were more likely to vote for a candidate if they supported expansion, while just 28% said it made them less likely to vote for a candidate.

Andrew Gillum in Florida, Stacey Abrams in Georgia, and Billie Sutton in South Dakota have all used their support for Medicaid expansion as key planks in their campaigns.

Read more: The 2018 midterms will have a big impact on healthcare, from Medicaid to nurses to abortion»

This isn't to say that the program would be expanded immediately if results go a certain way: State legislatures could stymie the expansion, as Virginia's legislature did for years despite the state's Democratic governor's wishes. Maine also voted to expand the program in 2017, but departing Gov. Paul LePage refused to expand the program.

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• Healthcare is the leading issue going into Tuesday's midterm elections, according to polling.
• One of the top healthcare-related campaign debates has come over protections for people with preexisting conditions.
• President Donald Trump and Republican candidates have argued that the party supports protections for people with preexisting conditions.
• Trump and the GOP's record flies in the face of that assertion.
• Here are 4 ways that Trump and the Republicans have sought to make people with preexisting conditions worse.

According to multiple polls, healthcare is the top issue for voters in Tuesday's midterm elections and one healthcare fight has dominated the airwaves: preexisting conditions.

Democrats have gone all out attacking Republicans for their attempts to strip preexisting condition protections away from Americans, and the GOP has been on the defensive.

President Donald Trump has continually claimed that his administration and the entire Republican Party's healthcare platform would provide as good, if not better, protections for people with preexisting conditions.

"Republicans will protect people with pre-existing conditions far better than the Dems!" Trump tweeted Wednesday, the latest in a slew of earlier tweets on the subject.

Read more: Republicans tried to kill Obamacare. Now they're trying to embrace its most popular feature in a defining fight of the midterms»

It's no wonder that Trump is focused on the issue: Voters rank healthcare among the most important issues for the upcoming midterm elections. Protecting preexisting conditions is a large— and popular — part of that concern.

The protections created in the Affordable Care Act, or Obamacare, made it so that insurance companies could:

• Not deny people coverage because of a preexisting condition, known as guaranteed issue.
• Not charge more because of a preexisting condition or any other health status, an idea called community rating.

Read more:Democrats are embracing a radical change to US healthcare, and it could be the defining political fight for years to come

But while Trump may toss out the suggestion that the GOP will provide similar preexisting condition protections for Americans, the actions of the administration and the party it represents are very much in conflict with that promise.

Outside of the GOP's eight-year crusade to repeal Obamacare, which created the protections, the Trump administration has recently attempted to undermine preexisting condition protections in various ways.

Here's a rundown of four different actions taken by Trump or the GOP that would harm the protections:

1. Short-term, limited-duration plans: These plans used to be only available to three months at a time and could not be renewed, but the Trump administration unveiled a rule that will now allow enrollees to stay on the plans for 12 months — re-enroll for up to three years. But these plans do not have to abide by Obamacare's preexisting condition rules, meaning people on these plans could face higher costs if they get sick.
   
   Additionally, these short-term plans could pull healthy people out of the Obamacare marketplace, leaving the pool sicker and more costly for insurers to cover. Insiders would then have to raise premiums to cover the Obamacare pool filled with people that need more robust care, including those with preexisting conditions.  (Read more on short-term plans »)
2. New guidance on Obamacare state waivers: On October 22, the administration released guidance on the use of the ACA's state innovation waivers, which were designed to give states the freedom to adjust their markets to bring down premiums. The guidance could allow states to expand the use of non-ACA compliant plans.
   
   Additionally — as with short-term, limited-duration plans — the guidance could pull healthier people out of the Obamacare marketplace, making the overall ACA pool sicker and more expensive to cover. (Read more on the wavier changes»)
3. The Obamacare lawsuit: Possibly the biggest outright threat to the ACA's preexisting conditions protection is a lawsuit filed by Texas Attorney General Ken Paxton and supported by 19 other state attorneys general (including GOP Senate candidates in Missouri and West Virginia) that would effectively repeal Obamacare entirely. Republicans argue that the repeal of the individual mandate in the GOP tax law passed in 2017 invalidates the rest of the ACA, including provisions that protect preexisting conditions.
   
   The Trump administration declined to defend the ACA, leaving Democratic state attorneys general to head up the defense. The case is still pending.
4. The GOP healthcare bill: The most high-profile example of the GOP possibly undermining preexisting condition protections were their attempts to repeal and replace Obamacare. While Republicans argue their bill, the American Health Care Act, would have protected preexisting conditions, most experts disagree.
   
   The law would have allowed states to receive waivers to create high risk pools in which sicker people could be placed, undermining community rating. The GOP argued they would give states funds to help combat higher costs, but experts generally agreed that the amount of money allocated was far short of what was needed.

SEE ALSO: Here's how much Obamacare premiums will increase in every state

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• Early exit polls show that a plurality of voters identified healthcare as the most important issue in the 2018 midterm elections.
• The polls could be a good sign for Democrats, who made healthcare their top issue during the campaign.
• Preelection polls also showed voters trusted Democrats over Republicans on healthcare.
• But exit polls can be unreliable and it's unclear how the focus influenced individual races.

Healthcare was the driving issue for many Americans in Tuesday's midterm elections, according to early exit polls, and the focus could be a good sign for Democrats.

According to early exit polls, healthcare was the most important issue for a plurality of voters in the midterms. An exit poll conducted by CNN, NBC, and other major outlets found 40% of Americans picking healthcare as their most important issue. Immigration came in second with roughly 20% of people selecting it as the top issue.

An exit poll conducted by the Associated Press' Votecast system also found that healthcare was the most important issue, but by a slimmer margin. 26% of Americans selected healthcare as the top issue with immigration nabbing a 23% share and 19% of people picking the economy.

Read more: Midterms 2018 LIVE: Follow along for live results and coverage of a wild election night

Healthcare was a dominant theme for Democrats throughout the election season with both House Minority Leader Nancy Pelosi and Senate Minority Leader Chuck Schumer imploring candidates to focus on the issue during the waning days of the campaign.

"I write to acknowledge the vital role Congressional Democrats played in protecting the Affordable Care Act and exposing the GOP’s monstrous health care agenda – and I urge all of us to continue to push this message in the next 24 hours," Pelosi said in a letter to colleagues on Monday.

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The focus on healthcare may also be a good, though incredibly early, sign for Democrats' hopes of retaking the House of Representatives. According to polling done before the election, Americans generally trusted the party more on healthcare and Democrats poured money into advertising on the issue.

Additionally, support for Obamacare and the law's preexisting conditions protections are at relative high points — both are issues that the Democrats harped on in the lead up to Election Day.

On the flip side, Trump and the GOP largely played defense on healthcare and attempted to turn the focus onto the strong economy or immigration issues like the migrant caravan. But that fight seems to have been blunted.

The results do come with a few caveats. Exit polls are prone to unreliability and just because voters were focused on healthcare doesn't mean that they voted for Democrats.

But Democrats largely wanted the midterm elections to be a referendum on the GOP's handling of healthcare and it appears the party got its wish.

SEE ALSO: A fight over the most popular piece of Obamacare could define the 2018 midterm elections

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• With Democrats' victory in the House, Obamacare repeal is dead.
• Democrats hold a strong advantage on healthcare and Obamacare looks stronger than ever.
• Three deep-red states expanded Medicaid, a key part of Obamacare, via ballot initiatives.
• Other states where Democrats won the governors' mansions could also undertake expansion.

Just two years after the future of the law was seriously in doubt, the results of Tuesday night's midterm elections solidified Obamacare's standing as the law of the land and showed that many aspects of the landmark healthcare law are getting more popular.

Democrats ran hard on the preservation of key aspects of the Affordable Care Act, a choice that many in the party credit for their House victory. A handful of states also voted to expand their Medicaid programs under Obamacare.

Democrats won the messaging fight on healthcare

With Democrats regaining control of the House, the GOP push to repeal and replace Obamacare is buried for the time being. If you ask Democrats, the prospect of another shot at repeal helped propel the party to victory.

Democratic Leader Nancy Pelosi, widely assumed to be the next speaker of the House, pointed directly to healthcare as the key to the party's path to the majority.

"It's about stopping the GOP and Mitch McConnell's assault on Medicare, Medicaid, affordable health care, and millions of Americans living with pre-existing medical conditions,"Pelosi said during a victory speech, referring to the Senate majority leader.

The ACA is polling near its highest level ever. And many of the law's provisions, including protections for people with preexisting conditions, remain significantly popular. The rising popularity and the GOP's legislative attacks on Obamacare allowed Democrats to draw a stark contrast with their Republican opponents.

Healthcare ranked as the top issue for voters in exit polling, and Americans generally trusted Democrats more than Republicans. According to an exit poll of 75 competitive, GOP-held districts by the left-leaning Public Policy Polling, 52% of people said they trusted Democrats more on healthcare, compared to just 44% who trusted the GOP more.

The switch represents a huge change from the 2010 and 2014 midterms, when Republicans hammered Democrats on the ACA and healthcare in general.

An outstanding question, however, is what exactly Congress could do to shore up Obamacare in a divided Congress. A bipartisan push to reinforce the law's individual insurance markets fell through in 2017, but McConnell hinted that another deal could be on the docket in 2019.

"We are going to have to try to address that on a bipartisan basis," McConnell said.

Medicaid expansion is a winner

Perhaps most significant for Obamacare's legacy is the continued popularity of the law's Medicaid expansion. The ACA allows states to expand Medicaid eligibility to people making up to 138% of the federal poverty limit, helping low-income Americans gain access to healthcare.

Expansion is heavily subsidized by the federal government to ease the cost burden on states, but many state-level Republicans have rejected the idea due to budgetary concerns. But slowly, the protestations of the GOP are giving way to a gradual march of Medicaid expansion.

Three deep-red states — Idaho, Nebraska, and Utah— joined the 32 expansion states via ballot initiatives on Tuesday. Solid majorities in each state voted for expansion, which will help roughly 325,000 people gain access to Medicaid.

In addition to the direct pick ups for expansion, a couple of governor's races could lead to additional gains:

• The Kansas legislature passed a bill to expand Medicaid in 2017, but it was blocked by then-Gov. Sam Brownback. Pro-expansion Democrat Laura Kelly took the governor's mansion, which could allow another crack at expansion and open to door for around 150,000 more people to enroll in Medicaid.
• Tony Evers, the Democratic governor-elect in Wisconsin, could also accept federal aid to boost the state's Medicaid program and extend coverage to another 176,000 people in the state.
• Additionally, Maine Gov. Paul LePage's refusal to implement Medicaid expansion despite a 2017 vote in favor of the move will likely be broken by the new Democratic Governor-elect Janet Mills. 70,000 people in the state could be eligible for Medicaid if expansion moves forward.

Other states could see expansion, like in North Carolina, where Republicans lost their supermajority in the state legislature, but that remains less likely.

In total, with the ballot initiatives and governors' races, up to 721,000 Americans could gain access to healthcare via Medicaid expansion in the wake of the midterms.

SEE ALSO: IT'S OFFICIAL: The GOP tax law was a political flop

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• In a ruling released Friday evening, a federal judge in Texas sided with 19 states arguing that key provisions of the Affordable Care Act or "Obamacare" are unconstitutional.
• The ruling brings new uncertainty to the country's healthcare markets, a day before the deadline to sign up for Affordable Care Act health plans in many states.
• The ruling doesn't go into effect immediately, and is almost certain to be appealed by state attorneys general who are defending the law.
• "As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster!" President Trump tweeted. "Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!"
• In a separate statement, the White House said, "We expect this ruling will be appealed to the Supreme Court. Pending the appeal process, the law remains in place."

In a ruling released Friday evening, a federal judge in Texas sided with states arguing that key provisions of the Affordable Care Act or "Obamacare" are unconstitutional.

The decision is almost certain to be appealed, but creates new uncertainty for the country's healthcare system. Per a White House statement, "We expect this ruling will be appealed to the Supreme Court. Pending the appeal process, the law remains in place."

Texas led 19 states arguing that the individual mandate — the requirement that everyone must have health insurance — is unconstitutional, after Congress gutted the key portion of the mandate, the tax penalty for not buying coverage.

U.S. District Judge Reed O’Connor in the Northern District of Texas agreed with those states and ruled the individual mandate unconstitutional. Because the mandate is an essential part of the ACA in the judge's view, that led him to rule that the entire health law should be struck down.

The law includes provisions that provide subsidies that help people buy coverage, its expansion of Medicaid to millions of low income people, and its protections that let people with pre-existing conditions buy insurance.

Repealing the Affordable Care Act could lead to about 15 million people losing their health insurance coverage, according to Ana Gupte, a Wall Street analyst at Leerink Partners.

"If this Texas decision on the ACA is upheld, it would throw the individual insurance market and the whole health care system into complete chaos," Larry Levitt, a senior vice president at the Kaiser Family Foundation said on Twitter. "But, the case still has a long legal road to travel before that’s an immediate threat."

Fourteen states along with the District of Columbia argued in favor of the law. However, the Trump administration sided with Texas et all. New York Attorney General Barbara Underwood said the states will continue their defense of the law.

"We’ll continue to fight in court for New Yorkers and all Americans," she said on Twitter.

The ACA has been a battle between Democrats, who favor the law, versus Republicans who have voted repeatedly to repeal it. The health law was passed in 2010.

President Donald Trump praised the decision, telling reporters Saturday that if the decision upheld, the administration would be working with Democratic lawmakers to secure "great, great health care for our people."

"We'll sit down with the Democrats, if the Supreme Court upholds, we'll be sitting down with the Democrats and we will get great health care for our people, that's a repeal and replace," Trump said. "On the assumption that the Supreme Court upholds, we will get great, great health care for our people."

The president added: "We'll have to sit down with the Democrats to do it, but I'm sure they want to do it also."

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• Democrats responded with fury on Friday night after a federal judge in Texas ruled that key provisions in the Affordable Care Act, otherwise known as "Obamacare," were unconstitutional — rendering the entire law unconstitutional.
• Some conservative groups praised the ruling, while other Republican lawmakers stayed silent.
• The federal judge ruled the individual mandate was unconstitutional, and that because it is "essential to and inseverable from the remainder of the ACA," the entire law is invalid.
• Here are some initial reactions from lawmakers and organizations.

Democrats responded with fury on Friday night after a federal judge in Texas ruled that key provisions in the Affordable Care Act, or "Obamacare," were unconstitutional— rendering the entire law unconstitutional.

Meanwhile in a tweet, President Donald Trump called for Congress to to pass a "STRONG" health care bill, and some conservative organizations and lawmakers praised the judge's decision.

US District Judge Reed O'Connor in the Northern District of Texas sided with 19 states led by Texas who argued that the individual mandate — the requirement that everyone must have health insurance — was unconstitutional after lawmakers repealed the tax penalty for not having insurance. Fourteen states and the District of Columbia were arguing in favor of the law.

The Trump administration sided with the 19 states' individual mandate argument, but also argued to keep some provisions of the bill, including Medicaid expansion and the health exchanges, according to Bloomberg.

The judge ruled the individual mandate was unconstitutional, and because it is "essential to and inseverable from the remainder of the ACA" the entire law is invalid.

The ruling could impact millions of Americans, including those with preexisting conditions. Since there is no injunction from the court, it is possible, one expert tweeted, that the law could stay in place while the ruling is appealed — and lawmakers like House Minority Nancy Pelosi have stated that the decision would be appealed.

Lawmakers and attorneys general quickly responded. Here are some initial reactions:

• President Donald Trump via Twitter: "As I predicted all along, Obamacare has been struck down as an UNCONSTITUTIONAL disaster! Now Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!"
• House Minority Leader Nancy Pelosi: "While the district court’s absurd ruling will be immediately appealed, Republicans are fully responsible for this cruel decision and for the fear they have struck into millions of families across America who are now in danger of losing their health coverage. When House Democrats take the gavel, the House of Representatives will move swiftly to formally intervene in the appeals process to uphold the life-saving protections for people with pre-existing conditions and reject Republicans’ effort to destroy the Affordable Care Act."
• Senate Minority Leader Chuck Schumer: "If this awful ruling is upheld in the higher courts, it will be a disaster for tens of millions of American families, especially for people with pre-existing conditions. The ruling seems to be based on faulty legal reasoning and hopefully it will be overturned. Americans who care about working families must do all they can to prevent this district court ruling from becoming law."
• Sen. Bernie Sanders via Twitter: "This is an outrageous, disastrous decision that threatens the health care and lives of millions of people. It must be overturned. We must move forward to make health care a right for every American."
• Sen. Sherrod Brown:"This decision threatens the health coverage of 20 million people and undermines pre-existing condition protections for all Americans. We cannot go back to the days when insurance companies could deny coverage for people who are sick. We will fight back,” said Brown. “Enrollment is still open through Saturday and no one should be intimidated by this ruling. You can still get coverage by going to www.healthcare.gov or calling 1-800-318-2596 by Saturday."
• Sen. Chris Murphy: "This is a five alarm fire -- Republicans just blew up our health care system. The anti-health care zealots in the Republican Party are intentionally ripping health care away from the working poor, increasing costs on seniors, and making insurance harder to afford for people with preexisting conditions,” said Murphy."
• Sen. Dick Durbin: "Today’s decision by a district court judge — backed by President Trump — is politics at its worst and threatens access to care for millions of Americans with pre-existing conditions. But this misguided decision will be appealed, and I am confident that common sense will prevail. Americans across the country should continue to sign up for health insurance through Saturday’s deadline."
• Sen Ron Wyden:"Today’s ruling is an assault on all Americans’ basic health care rights and judicial overreach at its worst,” Wyden said. “Trump and Republicans in Congress will achieve their long-sought goals if this ruling stands: the elimination of pre-existing condition protections and Medicaid coverage for millions of vulnerable Americans. Seniors will pay more for their prescriptions and middle-class families will lose tax breaks that keep their health care affordable. This judge chose to deliver his ruling the day before the end of open enrollment - a deliberate, ideological move to sabotage the Affordable Care Act at the expense of families’ health care. If you or your loved ones need health care, you should still sign up as planned at Healthcare.gov before the open enrollment deadline at end of the day tomorrow despite this attempted sabotage."
• Sen. Joe Manchin: "This misguided and inhumane ruling will kick millions of Americans and tens of thousands of West Virginians off of their health insurance. West Virginians with pre-existing conditions will be at risk of losing their health insurance. And the thousands of West Virginians who gained health insurance through the Medicaid expansion will no longer qualify. This ruling is just plain wrong. I look forward to its appeal to a higher court, and I intend to fight to ensure that the Senate has an opportunity to intervene to defend these critical health safeguards. I urge West Virginia’s Attorney General to withdraw from this dangerous lawsuit on behalf of the tens of thousands of West Virginians who will be harmed."
• House Majority Whip: "When Democrats forced Obamacare down the throats of the American people on a purely partisan basis, they threatened that the law needed to be passed so that people could find out what was in it. Over the last eight years since it was signed into law, we have found out that the Democrats who passed it caused millions of families to lose the plans and doctors they liked, and imposed unaffordable premiums and deductibles that undermine the basic coverage that families enjoy. Not only does tonight's ruling confirm that this broken law cannot hold up under court scrutiny, but it also affirms that the law does not actually protect people with preexisting conditions."

Organizations also weighed in

• American Medical Association President Barbara L. McAneny, M.D. : "Today’s decision is an unfortunate step backward for our health system that is contrary to overwhelming public sentiment to preserve pre-existing condition protections and other policies that have extended health insurance coverage to millions of Americans. It will destabilize health insurance coverage by rolling back federal policy to 2009. No one wants to go back to the days of 20 percent of the population uninsured and fewer patient protections, but this decision will move us in that direction."
• Joint statement from the American Cancer Society Cancer Action Network, American Diabetes Association, American Heart Association, American Lung Association and National Multiple Sclerosis Society: "This decision threatens to resurrect barriers to health care for people with serious illnesses including cancer, heart disease, stroke, lung disease, diabetes and those with neurological conditions. If the ruling stands, anyone with a pre-existing condition could be charged more for health coverage or denied access to coverage altogether. Health plans would no longer be required to offer essential benefits necessary to prevent and treat a serious condition and could once again impose arbitrary annual and lifetime limits on coverage. Invalidating the law also would jeopardize the federal tax credits that make health insurance affordable for more than 8 million Americans, threatening their access to critical health coverage."
• Think tank FreedomWorks:"Although Republicans in Congress have failed to repeal Obamacare in its entirety, this ruling has proven that their action to repeal the individual mandate in last year’s tax reform legislation was a consequential move. FreedomWorks agrees with the Judge O’Connor’s ruling that Obamacare is unconstitutional."
• Heritage Action Executive Director Time Chapman:"Americans should not fall for the tired myth from Democrats that only Obamacare protects pre-existing conditions. If Congress returns control of health care back to the states, it will give more Americans, even those with pre-existing conditions, greater access to affordable health care."

The deadline to enroll for coverage on Healthcare.gov is Saturday, December 15.

SEE ALSO: A federal judge just ruled that Obamacare is unconstitutional, threatening healthcare chaos

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• A federal judge on Friday evening ruled that Obamacare's individual mandate was unconstitutional and that the entire law should be struck down. 
• The decision will be appealed, and doesn't immediately take effect.
• Healthcare stocks linked to the law were under pressure Monday. 

Healthcare stocks were under pressure Monday morning after a federal judge ruled that Obamacare was unconstitutional. 

US District Judge Reed O'Connor in the Northern District of Texas agreed with the 19 states that argued the individual mandate in the Affordable Care Act, also known as Obamacare, was unconstitutional and that the entire law should be struck down. O'Connor's ruling won't immediately go into effect, and will likely be appealed.

Still, that didn't stop traders on Monday from dumping health insurer and hospital stocks that have big businesses tied to portions of the tied to the law. Here's a look at the scoreboard ahead of Monday's opening bell:

• Molina Healthcare (MOH): -7.59%
• Tenet Healthcare (THC): -7.43%
• Community Health Systems(CYH): -7.07%
• HCA (HCA): -6.05%
• Centene (CNC): -4.3%

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• A Texas judge on Friday ruled that Obamacare was unconstitutional.
• The lawsuit that led to the ruling was brought by Republicans. It used a law passed by the GOP as the crux of the argument.
• The judge struck down popular parts of Obamacare, which could force the GOP to come up with a plan to protect those elements or risk getting blamed for millions of people losing coverage.
• The problem is especially acute because the ruling would eliminate certain rules Republicans explicitly said they would keep safe, including protections for people with preexisting conditions. 

A federal judge's ruling on Friday declaring the Affordable Care Act (ACA) unconstitutional could leave Republicans stuck in political limbo as the fate of millions of people's healthcare remains unclear.

US District Judge Reed O'Connor's broad decision argued that because the GOP virtually eliminated the ACA's individual mandate as part of their tax law, the rest of the ACA — better known as Obamacare — was also unconstitutional.

The ruling, if upheld by higher courts, would eliminate a slew of hugely popular Obamacare provisions, ranging from protections for people with preexisting conditions to the ability for children to stay on their parent's healthcare plan until age 26.

So the risk for the GOP is that voters may see a ruling:

• Based on a case brought by Republican attorneys general;
• Not defended by the Trump administration;
• Citing a law passed exclusively with Republicans votes that takes away protections that are wildly popular and could leave as many as 20 million more Americans without coverage.

"The ruling once again elevates the debate on healthcare after Republicans had begun to move away from the issue in the 2018 midterm election cycle, as many candidates saw it becoming a net negative with voters," Ed Mills, a policy analyst at Raymond James, wrote Monday.

The risk is particularly acute because the GOP already has seen the political danger in losing the healthcare message battle. In the midterms, healthcare was the top issue for voters, and a majority of people trusted Democrats to better handle the issue — despite Republican candidates' embrace of issues like preexisting-condition protections.

Read more:Republicans made a lot of promises about preexisting conditions before the midterms

This massive advantage helped fuel the Democrats' large gain in the House.

The concern over the ruling was apparent, as few prominent Republicans rushed to celebrate the ruling, and some formerly pro-repeal leaders were uncharacteristically mum. For instance, House Speaker Paul Ryan only issued a short statement via a spokesperson: "The House was not party to this suit, and we are reviewing the ruling and its impact."

Greg Valliere, chief global strategist at Horizon Investments, said the ruling adds another aspect to the Republicans' recent troubles with healthcare and will force the party into coming up with a concrete solution.

"Ironically, most Republicans reacted — in private — with dismay because they will once again get saddled with the burden of coming up with a replacement — and because their efforts to kill the law have jeopardized popular health provisions," Valliere said.

Without a serious plan to protect the popular parts of the ACA, Republicans could end up in an even worse spot than they did during the midterms. But so far, every GOP replacement plan has polled dismally with Americans — and coming up with an idea that simultaneously protects the popular parts of Obamacare, preserves coverage gains, and appeals to the anti-Obamacare Republican base could prove difficult.

Given the pitfalls, some Republicans were scrambling to reassure people that the ruling itself would likely be overturned and there was no reason to worry.

"The judge's ruling was far too sweeping," Sen. Susan Collins, who voted against the GOP's attempts to repeal and replace Obamacare, said on ABC. "He could have taken a much more surgical approach and just struck down the individual mandate and kept the rest of the law intact. I believe that it will be overturned."

On the flipside, the decision could also be a boon for Democrats. Senate Minority Leader Chuck Schumer told NBC's "Meet the Press" on Sunday that Democrats plan to use the case to put pressure on the GOP to help preserve protections. 

"The first thing we’re going to do when we get back there in the Senate is urge, put a vote on the floor, urging an intervention in the case," Schumer said. "The judge — a lot of this depends on congressional intent. And if a majority of the House and a majority of the Senate say that this case should be overturned, it'll have a tremendous effect on the appeal."

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• Judge Reed O'Connor's ruling declaring the entire Affordable Care Act, or Obamacare, unconstitutional took many experts by surprise.
• Many health-policy experts questioned O'Connor's legal judgement and pointed to his long history of favoring conservative positions and attacking the ACA.
• The experts also agreed that the ruling would likely be overturned.

The shock decision by Judge Reed O'Connor on Friday that ruled the Affordable Care Act (ACA), or Obamacare, is unconstitutional was made with a partisan tinge and likely will not stand, experts said.

Health-policy experts from across the political spectrum rejected O'Connor's reasoning for the decision and expected it would be overruled on appeal.

O'Connor's decision determined that when Congress reduced the ACA's individual mandate — or penalty for not having health insurance — to $0, the rest of the law became effectively unconstitutional. This is a broad view of Congress' intent, legal scholars said.

"Congress amended one provision of a 2,000 page law and did not touch the rest of the law so it is implausible to believe that Congress intended the rest of the law not to exist," Abbe Gluck, a health-law expert at Yale Law School, said following the ruling.

Under O'Connor's decision, the entirety of the ACA would be thrown out, including popular provisions like preexisting-condition protections. Given that such changes could throw the healthcare system into chaos and leave as many as 20 million people without insurance, the ruling has caused an uproar among both politicians and healthcare advocates.

In a Washington Post op-ed, Nicholas Bagley, a law professor with a focus on health policy at the University of Michigan, failed to make sense of O'Connor's legal case. He determined that the "logic of the ruling is as difficult to follow as it is to defend."

"This case is different; it's an exercise of raw judicial activism,"Bagley said. "Don't for a moment mistake it for the rule of law."

O'Connor has been labeled a favorite judge of conservative lawyers and has ruled against Obamacare on numerous occasions. 

And even many Obamacare critics have spoken out against the ruling. Conservative lawyers that previously criticized the law took issue with the breadth of the ruling. Philip Klein, the executive editor of the conservative-leaning Washington Examiner and author of a book on "overcoming" Obamacare, called it an "assault on the rule of law."

"If Congress repealed all of Obamacare tomorrow, I'd throw a party. Despite my policy preferences, I'd say the latest decision from U.S. District Court Judge Reed O'Connor of Texas declaring Obamacare unconstitutional is an assault on the rule of law," he wrote in an op-ed Monday.

While most experts agree that O'Connor overstepped, the prevailing sense is that nothing will change for the time being.

The judge issued what is known as a declaratory judgment — which, unlike an injunction, allows the law to continue unabated until the case is taken up by another court. Democratic states have pledged to appeal the ruling, so O'Connor's decision will likely not be the last word. Meanwhile, people who get access to healthcare through Obamacare's marketplaces or Medicaid expansion will continue to have coverage.

Looking to the future, many health policy experts also believed a higher court — whether it's an appellate court or Supreme Court — will eventually reject O'Connor's huge scope.

"This is insanity in print, and it will not stand up on appeal," Bagley tweeted on Friday.

SEE ALSO: A federal judge's ruling declaring Obamacare unconstitutional leaves the GOP between a rock and a hard place

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• Sign ups for Obamacare health insurance plans through the Healthcare.gov marketplace fell 4% for 2019.
• While this is the second straight year that enrollment declined, the final tally is much better than earlier numbers suggested.
• The drop was due to a slew of reasons ranging from the repeal of the individual mandate in the GOP tax law to Virginia's expansion of Medicaid.

Obamacare enrollment declined for the second straight year, but the number of people enrolling in health insurance plans for 2019 remained relatively resilient following a year of uncertainty fueled by President Donald Trump and Republicans in Congress.

Enrollment in Affordable Care Act health plans through the federally-managed Healthcare.gov platform totaled about 8.5 million during this year's open enrollment period, down 4% from last year, according to preliminary data released Wednesday by the Centers for Medicare and Medicaid Services.

34 of the 39 states that use Healthcare.gov reported enrollment declines compared to the same period in 2017, with just Wyoming, Hawaii, Florida, Mississippi, and Oklahoma showing increases. Others states, such as New York and California, run their own sign-up systems and have different deadlines.

Read more: Here's how much Obamacare premiums will increase in every state

The numbers come as a substantial rebound for enrollment. Previous weekly updates from CMS showed enrollment on track to fall as much as 12% year-over-year. A lot of people usually sign up for health plans right around the deadline, which was December 15.

Matthew Borsch, an analyst at BMO Capital Markets, said the sign-up figures were better than he expected. 

"This is good for the ACA exchanges and we think makes it highly likely we will see a stable risk pool next year," he said.

Larry Levitt, a senior vice president at the health policy think tank The Kaiser Family Foundation, said the numbers prove the continued strength of the Obamacare market despite a slew of changes by the Trump administration.

"With 8.5 million people signed up for health insurance for 2019 in the federal ACA marketplace, it is far from dead and remarkably resilient," Levitt tweeted Wednesday.

These enrollment numbers are preliminary, and last year's total fell slightly between the end of open enrollment and CMS's final evaluation.

Obamacare faced a lot of challenges during this sign-up season

There were a slew of challenges facing Obamacare during the sixth open enrollment period, with everything from the elimination of the individual mandate to the expansion of Medicaid in Virginia contributing to the slowdown in sign-ups.

Seema Verma, the chief of CMS, told reporters that the overall sign-up numbers were "steady as compared to previous years" and proved that the Trump administration had stabilized the marketplaces. Verma also pointed to the strong economy as a key reason for the enrollment decline.

"People are now getting jobs and those jobs are providing health insurance, so those individuals may not need to come to the exchange to get health coverage," Verma said.

In addition to the strong economy, some of the factors that makes the enrollment numbers even more impressive are:

• The elimination of the individual mandate, the financial penalty for not having insurance. The penalty was decreased to $0 as part of the GOP tax law, making it possible for people to decline coverage without facing a financial hit.
• The Trump administration's drastic cuts to Obamacare's advertising and outreach budget which fell to $10 million from $100 million during the Obama administration. Verma disputed the notion that the advertising cuts made a difference in enrollment. "We see no correlation between what we’re spending on advertising and effectuated enrollments," she said.
• The expansion of short-term, limited-duration plans by the Trump administration. The plans offer a cheaper alternative for younger and healthier consumers, but carry increased risk since the plans offer less coverage.
• The expansion of Medicaid in Virginia. The state saw the largest drop in enrollees this year, and Verma said about 100,000 people who previously bought exchange plans were now eligible for Medicaid coverage.
• Uncertainty over the future of the law, likely exacerbated by a judge's ruling on Friday— the day before the final day of enrollment — that the entire Affordable Care Act (Obamacare's official name) is unconstitutional.

Add up all of those factors and you've got the recipe for the enrollment decrease.

West Virginia saw the biggest decline in enrollment compared to last year.

Rusty Harvilla has been helping people in West Virginia sign up for ACA health plans since 2013. He said he thinks two big changes are responsible for the decline: the end of Obamacare's requirement that everybody buy insurance, and a big reduction in advertising and enrollment support from the Trump administration.

Harvilla said he often got phone calls from people asking if they still had to buy health insurance this year. He said he'd answer that they didn't have to buy it, but he'd also tell them it was a good idea to be covered.

"I had that question a lot this time around,'' he said. "And I would be honest with them and say no, you don’t have to buy it."

Harvilla said Obamacare has never been popular.

"It's toxic," Harvilla, a certified application counselor at Clay-Battelle Health Services, said by phone. "If they bring it up, we try to steer them toward ACA, the marketplace, those kind of terminologies."

Still, he said, people are usually grateful for the coverage.

Here's a breakdown of state-by-state changes in enrollment, compared to enrollment through December 15, 2017, from largest drop to smallest:

• West Virginia -18.74%
• Virginia -17.11%
• Louisiana -16.22%
• Indiana -11.00%
• New Hampshire -10.63%
• New Mexico -10.50%
• Ohio -10.34%
• Missouri -9.35%
• Wisconsin -9.05%
• Delaware -8.86%
• Kansas -8.82%
• Nevada -8.04%
• New Jersey -7.96%
• Iowa -7.79%
• Michigan -7.69%
• Illinois -7.35%
• Pennsylvania -6.75%
• Maine -6.41%
• Oregon -5.75%
• Montana -5.61%
• Kentucky -5.38%
• Georgia -4.71%
• North Dakota -4.54%
• North Carolina -4.11%
• Texas -3.62%
• Arizona -3.43%
• Tennessee -3.11%
• Alaska -2.89%
• South Dakota -2.67%
• Arkansas -1.75%
• Alabama -1.73%
• South Carolina -0.71%
• Nebraska -0.56%
• Utah -0.16%
• Wyoming 0.19%
• Hawaii 1.15%
• Florida 3.20%
• Mississippi 5.56%
• Oklahoma 6.60%

SEE ALSO: Experts think the ruling that declared Obamacare unconstitutional is 'insanity in print' and will likely be overturned

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• The new Democratic-controlled House has filed papers seeking to intervene in a federal court ruling that Obamacare is inconstitutional.
• The chamber plans to vote next week to authorize its attorneys to enter the case and defend the law.
• This is designed to force Republicans to choose between seeming to defend the statute they have long despised or supporting the demise of its widely popular benefits.
• By itself, it is unlikely to have a substantial impact on the litigation, and the greatest impact is likely to be political.

WASHINGTON (AP) — The new Democratic-controlled House has moved toward defending former President Barack Obama's health care law against a federal court ruling that the statute is unconstitutional, part of the party's effort to use the issue to embarrass Republicans.

The House has filed papers seeking to intervene in the case, Democrats announced Friday, which by itself is unlikely to have a substantial impact on the litigation. The House action's greatest impact is likely to be political.

The chamber plans to vote next week to authorize its attorneys to enter the case and defend the law. That is designed to force Republicans to choose between seeming to defend the statute they have long despised or supporting the demise of its widely popular benefits.

"While the administration refuses to meet its responsibilities to defend the laws, the House of Representatives is acting to uphold the constitutionality of this law and protect the health care of every American," House Speaker Nancy Pelosi, D-Calif., said in a written statement.

In June, Trump administration lawyers stopped defending key parts of the law, including its guaranteed access to health insurance for people with pre-existing medical conditions.

The Justice Department usually defends federal laws in court, but Trump has long unsuccessfully sought to repeal the health care statute. Congressional Republicans unanimously opposed the 2010 law and have voted repeatedly to repeal it.

The statute has gained public acceptance, particularly its protections for people with pre-existing conditions. To defend themselves during last fall's campaigns, many Republicans said they'd back legislation ensuring coverage for people with pre-existing medical issues.

A federal judge in Texas said last month that the law was unconstitutional because Congress repealed its fines on uninsured people. The suit has moved to the 5th U.S. Circuit Court of Appeals in New Orleans, and in the meantime the law's provisions remain in effect.

The House voted Thursday — the first day of the new Congress — to give preliminary approval to its attorneys to enter the case, a provision that was part of a broad package of rules the chamber adopted. Democrats intended the early vote to signal that health care is a high priority.

During that debate, Republicans offered a non-binding measure saying lawmakers should produce legislation protecting consumers with pre-existing conditions. Democrats blocked it.

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• The health-insurance startup Oscar Health just came out with its full-year results for 2018.
• According to state insurance filings reviewed by Business Insider, Oscar lost $57 million in 2018, an improvement from a loss of $131 million in 2017.
• Oscar said it posted gross premium revenue of $1.2 billion.
• Oscar told Business Insider that about 257,000 people enrolled in its plans across nine states for 2019, up from the 239,000 it signed up for 2018.
• Oscar's results are improving, and the startup is pursuing a new strategy to keep growing.

Oscar Health has officially cracked $1 billion in premium revenue. 

The health insurance startup mainly sells insurance on the individual exchanges set up by the Affordable Care Act, and took in $1.2 billion in gross premium revenue in 2018. Oscar's financial losses narrowed to $57 million, from $131 million in 2017, according to state financial filings.

Yet Oscar is facing slow growth, a big problem for a startup valued at $3.2 billion. The company nearly doubled its footprint for 2019, expanding into six new markets. Membership, though, increased by just 18,000 between 2018 and 2019, to a total of 257,000 people. That's thanks in part to tough competition in some of the company's new markets: Oscar signed up just 2,000 people in Arizona and 1,000 in Michigan in the individual market. 

Prepping for the Medicare Advantage market

The financials and enrollment figures make it clear why Oscar is expanding its reach into a lucrative new market: Medicare Advantage. The Affordable Care Act's exchanges have been challenging for health insurers, with a numberleaving the business altogether. In the ACA, which is often called Obamacare, enrollees tend to buy cheaper plans, making it difficult for companies like Oscar to offer more expensive options.

In 2020, Oscar will start offering private health-insurance plans to seniors, which are known as Medicare Advantage plans. The company hasn't yet said where it will sell those plans.

Read more: We got a look at the slide deck that buzzy startup Devoted Health used to hit a $1.8 billion valuation before it signed up any customers

It's an area startups and big insurers alike have been flocking to. For instance, Devoted Health launched its first plans in 2019 in Florida after raising more than $300 million from investors. Clover Health, a startup founded in 2014, now offers Medicare Advantage plans in seven states. The startups are competing with big, entrenched insurers like Humana, UnitedHealth Group, and CVS Health.

Oscar in August 2018 raised $375 million from Google's parent company Alphabet, and said it would use the funds to bring its tech-backed health insurance plans to more people, including in Medicare Advantage. In total, the company has now raised more than $1 billion.

Oscar's new chief financial officer, Sid Sankaran, said expanding into Medicare Advantage will be a focus of Oscar's energy over 2020 and 2021. 

"We know that that is a space with a lot of players, he said. "We’re thinking about how to scale and build that business."

In 2018, Oscar offered health-insurance plans on the Obamacare marketplaces in New York, New Jersey, California, Ohio, Texas, and Tennessee. It also sells plans for small employers. For this year, the company expanded into six new markets across three states: Arizona, Michigan, and Florida.

The health insurer's 2018 financials show its operations are improving. The company said it has managed to get medical costs under control, spending about 80.5% of the premium revenue it takes in from its members on medical care, down from about 95% the year before. That resulted in a net underwriting profit of $141 million in 2018, up from $10 million in 2017, Oscar told Business Insider.

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Those figures don't include spending on investment the company is making in hiring new people or building out its technology, nor its marketing costs to get the word out about the plans.

Oscar's financial results are affected by a reinsurance deal that the company entered into with the massive French insurer Axa. A portion of the premiums that Oscar collects are sent to Axa, and in return Axa agrees to share a portion of Oscar's profits or losses.

When factoring in the money that was sent to Axa, Oscar took in about $725 million in premiums across its states in 2018, according the company's filings. 

In February, Oscar hired Sankaran, a former executive at the insurer American International Group, as its chief financial officer. Sankaran most recently served as the global insurance giant's CFO and was chief risk officer as the company recovered from the financial crisis, when it was bailed out by the US government. 

"I was raised in captivity in insurance and financial services," Sankaran told Business Insider he likes to joke.

Sankaran officially starts March 1, but he's been hanging out at the offices in Soho for the past month after dropping his kids off at school to get a feel for the place. He said what's stood out to him about Oscar is the company's focus on tech and making health insurance and medical care easier for members to access, particularly through programs like telemedicine.

Sankaran has a saying: "In insurance, you can trade off three things: profitability, growth, risk." His goal at Oscar is to balance those three things  to create a long term company. And given his experience at a larger company like AIG, his plan is to use his expertise to help scale Oscar.

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• The company that runs health clinics for Facebook and LinkedIn just made a big bet that the future of healthcare is moving online
• A doctor's office that charges a monthly fee and doesn't take insurance wants to stop the 'revolving door' of appointments for sick kids

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• Former Vice President Joe Biden is readying a 2020 presidential run after opting not to jump in the race in 2016.
• Biden has significant advantages over the growing Democratic field, including name recognition and long and diverse record of public service.
• But Biden could also be forced to come to grips with changes in the Democratic Party, among other factors that could derail a presidential bid.

Former Vice President Joe Biden is inching closer to a 2020 run, but could face a series of hurdles if he jumps in the race. 

No candidate is perfect, even if they poll very high. And every candidate has their own unique flaws that if exposed or highlighted by opponents, could derail their chances of obtaining the Democratic presidential nomination.

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Biden has a lot going for him. He had eight relatively successful years in the Barack Obama administration, enjoys significant name recognition, and is already polling at the top of the field, even over many Democrats who have already jumped into the race.

But Biden has several flaws in key areas as well.

Behavior with women

In the era of the #MeToo movement, there is a spotlight on individuals in positions of power and how they conduct themselves. For years during the Obama administration, Biden was the subject of viral images and videos showing him hugging and kissing female supporters and acquaintances.

Women have not accused Biden of any sexual improprieties or harassment, but the track record has left many progressives feeling uneasy about him.

"Biden is the wrong guy to bear the standard of any party purporting to speak for the victims of unaccountable power,"wrote HuffPost Washington Bureau Chief Amanda Terkel.

Biden has also faced criticism for his handling of the confirmation of Supreme Court Justice Clarence Thomas in 1991 while he chaired the Senate Judiciary Committee. Thomas was the subject of sexual harassment allegations from Anita Hill, an employee of Thomas' at the Department of Education.

"He owes all of us an apology," Hill told the Boston Globe while recounting the process. "He owes the country an apology because the affront was not just to me. It was really a disservice to every one of us — not just on behalf of sexual harassment victims but also on behalf of those people who believe in the integrity of the court and that it should be protected by the Senate, whose role is to advise on judicial nomination."

Biden has expressed regret about the process, but maintains that he understood women's issues back then.

"The woman should be given the benefit of the doubt and not be abused again by the system," Biden told NBC News in a 2018 interview. "My biggest regret was, I didn't know how I could shut you off because you were a senator and you were attacking Anita Hill's character ... She got victimized during the process."

Biden also noted in the interview he helped craft the Violence Against Women Act.

A long career in politics

Biden spent 36 years in the United States Senate before becoming vice president, during which he chaired powerful committees like the Judiciary and Foreign Relations panels. That creates an extensive and easily searchable archive for opponents to dig up dirt that could damage his progressive chops.

Politics and what is acceptable, particularly in the Democratic Party, have significantly changed throughout the past few decades.

With already-announced candidates like Sen. Kamala Harris already backtracking on her career as California attorney general, Biden could face similar criticisms on hot-button issues like criminal justice.

In an unearthed 1993 Senate floor speech unearthed by CNN, Biden railed against "predators" and other criminals while pushing the Violent Crime Control and Law Enforcement Act.

"They are beyond the pale many of those people, beyond the pale," Biden said at the time. "And it's a sad commentary on society. We have no choice but to take them out of society."

That kind of rhetoric, which at the time was mainstream, now draws widespread condemnation from much of the Democratic Party and could haunt him during a dogfight in a crowded primary race.

The Democratic base has moved increasingly far left in recent years

Biden has considerable experience and close ties across key areas that Democrats failed to capture in the 2016 presidential election, like parts of the Rust Belt and Midwestern United States. But Biden is a lot less liberal compared to many Democrats who have jumped into the race, as well as their core group of supporters in the party's base.

Biden will also have to come to grips with a whole host of other issues hardcore progressives are zeroing-in on, like the proposed "Green New Deal," a transformative moonshot to combat global climate change, pledges to abolish the legislative filibuster, and significant tax increases on the wealthy and large corporations.

Another major reform Democrats are getting on board with is universal health care, which they have coined as "Medicare for All."

Biden was a central figure in advancing the Affordable Care Act, otherwise known as Obamacare. A Medicare for All plan would scrap that entirely and replace a signature achievement of the administration in which he was a pivotal figure. 

He could be overly confident

Like Hillary Clinton was in 2016, Biden is very confident about his chances of beating Donald Trump. 

"I’ll be as straight with you as I can," Biden said in December. "I think I’m the most qualified person in the country to be president. The issues that we face as a country today are the issues that have been in my wheelhouse, that I've worked on my whole life."

Biden has also made a point of noting he could easily defeat Trump, including in a literal fist fight. 

"They asked me if I'd like to debate this gentleman, and I said 'no.' I said, 'If we were in high school, I'd take him behind the gym and beat the hell out of him,'" Biden said in 2018.

Trump responded by calling Biden weak, noting that he could beat up the former vice president.

"Crazy Joe Biden is trying to act like a tough guy. Actually, he is weak, both mentally and physically, and yet he threatens me, for the second time, with physical assault," Trump wrote on Twitter. "He doesn't know me, but he would go down fast and hard, crying all the way. Don't threaten people Joe!"

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• Democratic presidential candidate Beto O'Rourke backed a public option system in which Americans could keep their private health insurance or participate in Medicare.
• Many of the other Democratic candidates running for president in 2020 are supporting a "Medicare for all" proposal instead.

Democratic presidential candidate Beto O'Rourke said he would support a health care system that allows Americans to participate in Medicare or keep their existing employer-based and private health insurance coverage.

Backing the "public option" plan differentiates O'Rourke from a handful of the other Democratic presidential candidates and more liberal base, who have made a point of explicitly backing a "Medicare for All" style program.

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"Two extraordinary women with whom I served in Congress, Jan Schakowsky of Illinois, Rosa DeLauro of Connecticut have introduced a proposal called 'Medicare for America' that ensures that if you have employer-based insurance and if you like it, you keep it. Your doctors, your network, what works for you right now," O'Rourke said at an event at Penn State University on Tuesday. "If you don't have insurance or you don't like the insurance you already have, you enroll in Medicare."

Put another way, the plan would move everyone who is on Medicaid, gets coverage through the Obamacare exchanges, or does not have insurance onto the government's Medicare program. Seniors currently on Medicare would continue to receive those benefits.

In addition, Americans of any age would then be allowed to either receive insurance through their employer or opt into the government option.

O'Rourke also said that such a proposal will come at a steep price, but noted he believes it is prudent in the long run.

"It'll be measured in the trillions of dollars," he said. "It is not inexpensive, but as I made the point and the case earlier, it's a lot less expensive than taking care of people at end of life who have never been treated in the first place."

During his unsuccessful Senate run in Texas during the 2018 midterm elections, O'Rourke told INSIDER his "number one campaign issue" was "universal health care."

Other Democrats have coalesced around a 'Medicare for All' system

Democratic candidates like Vermont Sen. Bernie Sanders and California Sen. Kamala Harris have back a more comprehensive overhaul of the US health care system.

Medicare for All would include moving the health insurance market into a single-payer system where everyone received their coverage from the government program.

Sanders is one of the most prominent backers of Medicare for All, leading the drafting of a bill in the Senate. While the Vermont senator has long been an advocate for the idea, many of the other presidential candidates have embraced some version of the plan.

Harris came under fire for suggesting that an elimination of private insurance would be necessary in an ideal Medicare for all type system.

"Well, listen, the idea is that everyone gets access to medical care, and you don’t have to go through the process of going through an insurance company, having them give you approval, going through the paperwork, all of the delay that may require," she said in a town hall interview with CNN's Jake Tapper. "Who of us has not had that situation where you’ve got to wait for approval, and the doctor says, well, I don’t know if your insurance company is going to cover this. Let’s eliminate all of that. Let’s move on."

Republicans scoffed at the idea of abolishing private health insurance and potential independent presidential candidate and former Starbucks CEO Howard Schultz panned it as "not American."

"What’s next? What industry are we going to abolish next? The coffee industry?" he said.

Medicare for All generally receives strong favorability, but support for the health care transformation plummets when poll respondents are told it would require dramatic tax increases, according to a survey from the Kaiser Family Foundation.

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• The Trump administration said in a Monday court filing that it supports striking down the entire Affordable Care Act.
• In two sentences, the Department of Justice made an about-face on its previous stance on the health care law colloquially known as "Obamacare."
• "The Department of Justice has determined that the district court’s judgment should be affirmed,"the letter to the US Court of Appeals for the Fifth Circuit reads.
• Led by California Attorney General Xavier Becerra, a group of 17 attorneys general are defending the law.

The Trump administration said in a Monday court filing that it supports striking down the entire Affordable Care Act.

In two sentences, the Department of Justice made an about-face on its previous stance on the health care law colloquially known as "Obamacare."

"The Department of Justice has determined that the district court’s judgment should be affirmed,"the letter to the US Court of Appeals for the Fifth Circuit reads. "Because the United States is not urging that any portion of the district court’s judgment be reversed, the government intends to file a brief on the appellees’ schedule."

The letter refers to a December decision by US District Judge Reed O'Connor in the Northern District of Texas, which ruled that the individual mandate — which is at the crux of the law — is unconstitutional and therefore the entire health care law is unconstitutional.

In 2012, the Supreme Court upheld the individual mandate as a tax penalty: you could be taxed if you weren't covered; in 2017, the Tax Cut and Jobs Act eliminated the tax penalty for those who didn't have health insurance, and in February 2018, Texas and 19 other states filed a lawsuit saying that the individual mandate was now unconstitutional.

Judge O'Connor agreed and said that the entire law could not stand. That decision was appealed and the lawsuit is currently in a federal appeals court.

Under the former Attorney General Jeff Sessions, the DOJ declined to defend provisions protecting people with preexisting conditions — but said the rest of the law could stand, CNN reported. The ACA also includes Medicaid expansion, subsidies to help people purchase insurance, an allowance for kids to stay on their parents' insurance until they are 26 years old, and more.

Now, in an apparent shift, the DOJ under the current attorney general William Barr is siding with the judge's ruling.

"The Department of Justice has determined that the district court's comprehensive opinion came to the correct conclusion and will support it on appeal," Kerri Kupec, a DOJ spokesperson, told CNN.

Led by California Attorney General Xavier Becerra, a group of 17 attorneys general are defending the law, and last week newly-elected Democratic governor of Wisconsin Tony Evers pulled his state out of the lawsuit against the ACA.

The complete dissolution of the ACA would upend the current health care system and could leave millions without health insurance.

On Monday, the Associated Press reported that "11.4 million people have signed up for coverage this year under former President Barack Obama's health law."

After the filing, Obamacare supporters and Democratic lawmakers issued statements condemning the Trump administration's decision. Some also criticized Barr's decision to not support one of the country's laws in court.

"The ACA means health care coverage for 800,000-plus more people in Washington," Gov. Jay Inslee wrote on Twitter after the news broke. "Trump is attacking our health care again. We've stopped them before and we'll stop them again. Hands off our healthcare."

Democrats won a majority in the House of Representatives, running in part on protecting health insurance for Americans; many of the 2020 Democratic candidates are also running on expanded access to health care— including supporting proposals like Medicare for all.

President Donald Trump, for his part, has promised health care solutions. However, Republicans have been unsuccessful in "repeal and replace" attempts in Congress.

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• Oscar Health is looking to enter new states in the coming years, including Georgia and Illinois, according to filings reviewed by Business Insider.  
• The $3.2 billion health insurance startup got its start selling plans on the individual exchanges set up under the Affordable Care Act, but in recent years has expanded to sell plans to small employers and in 2020 it expects to offer plans to seniors, also known as Medicare Advantage plans.
• A spokeswoman for Oscar said in a statement that the moves was in preparation of operating in new markets, but didn't necessarily mean the states would be included in the company's 2020 footprint.

Oscar Health is plotting an expansion to its geographic reach. 

According to a regulatory filing reviewed by Business Insider, the health insurance startup has registered as an insurer in Georgia. The company has also incorporated in Illinois, a sign that it's planning to move into markets the two states.

A spokeswoman for Oscar said in a statement that the moves was in preparation of operating in new markets but didn't necessarily mean the states would be included in the company's 2020 footprint. As of 2019, Oscar offered health-insurance plans on the Obamacare marketplaces in 9 states: Arizona, California, Florida, Michigan, New Jersey, New York, Ohio, Texas, and Tennessee. It also sells plans for small employers.

"Oscar is committed to expanding our footprint so we can offer our tech-driven, consumer-facing health insurance to more people across the country," the spokeswoman said. "There are regulatory requirements with which we need to comply and licenses we need to obtain in order to operate in new markets. These new entities are merely preparatory and, pending approval, we will announce our 2020 footprint and the products we will offer in each market later this year."

It's happening at a time when Oscar is plotting its expansion into a competitive new plan market. In 2020, Oscar will start offering private health-insurance plans to seniors, which are known as Medicare Advantage plans. The company hasn't yet said where it will sell those plans. 

Oscar's 2018 financials and 2019 enrollment

The health insurance startup mainly sells insurance on the individual exchanges set up by the Affordable Care Act, and took in $1.2 billion in gross premium revenue in 2018. Oscar's financial losses narrowed to $57 million, from $131 million in 2017, according to state financial filings.

Yet Oscar faced slowing growth in 2018, a big problem for a startup valued at $3.2 billion. The company nearly doubled its footprint for 2019, expanding into six new markets. Membership, though, increased by just 18,000 between 2018 and 2019, to a total of 257,000 people.

That's thanks in part to tough competition in some of the company's new markets: Oscar signed up just 2,000 people in Arizona and 1,000 in Michigan in the individual market. 

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The financials and enrollment figures make it clear why Oscar is expanding its reach into a lucrative new market: Medicare Advantage. The Affordable Care Act's exchanges have been challenging for health insurers, with a numberleaving the business altogether. In the ACA, which is often called Obamacare, enrollees tend to buy cheaper plans, making it difficult for companies like Oscar to offer more expensive options.

It's an area startups and big insurers alike have been flocking to. For instance, Devoted Health launched its first plans in 2019 in Florida after raising more than $300 million from investors. Clover Health, a startup founded in 2014, now offers Medicare Advantage plans in seven states. The startups are competing with big, entrenched insurers like Humana, UnitedHealth Group, andCVS Health.

Oscar in August 2018 raised $375 million from Google's parent company Alphabet, and said it would use the funds to bring its tech-backed health insurance plans to more people, including in Medicare Advantage. In total, the company has now raised more than $1 billion.

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