Obamacare could be set for a Supreme Court showdown, after a Texas District Court judge ruled the law is “unconstitutional”.

The Affordable Care Act (ACA) as it is formally known, is the signature domestic policy achievement of the Obama administration. It provides cover for around 20 million Americans and has seen the uninsured rate for non-elderly adults drop from 18.2% to 10.3% in the eight years since it was introduced.

Vehemently opposed by Republicans as a form of socialised-medicine, the ACA has survived numerous legal challenges over the years, and an attempt by lawmakers in 2017 to repeal and replace it was met with widespread public opposition that eventually saw Congress back down.

Now a US federal judge in Texas has delivered a potentially fatal blow.

As part of Donald Trump’s tax overhaul passed last year, the ACA penalty for not having health insurance was abolished. Last week, Judge Reed O’Connor agreed with a group of Republican-led states and the Trump administration that with the elimination of the health insurance requirement there is no longer a tax, and therefore the law loses its constitutionality.

In brief, “once the heart of the ACA — the individual mandate — is declared unconstitutional, the remainder of the ACA must also fall,” the lawsuit stated.

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!

— Donald J. Trump (@realDonaldTrump) December 15, 2018

“Suffice to say, removing the individual mandate does not invalidate ACA on policy grounds,” writes Joshua Cohen in Forbes. “It weakens it, for sure. Indeed, the individual mandate is an integral component of the law, because it facilitates pooling of risk and expands population-wide access. But, it is not a necessary part of the law. ACA can function without it.”

“The ruling, issued late on Friday and only one day before the end of the law’s annual open enrollment period, is not a model of constitutional or statutory analysis,” says Cristian Farias in the New York Times. “It’s instead a predictable exercise in motivated reasoning — drafted by a jurist with a history of ruling against policies and laws advanced by President Barack Obama.”

The decision has also been blasted by the American Medical Association who called the ruling “a stunning display of judicial activism”.

The case is expected to be referred to the US Court of Appeals, and then possibly on to the Supreme Court for a final ruling.

To say their decision is literally a matter of life and death is no understatement.

“Whether you know it or not, Obamacare has affected nearly every American,” says CNN’s Tami Luhby.

As well allowing millions of people to get health insurance through exchanges or Medicaid expansion, “it saves senior citizens money on their Medicare coverage and prescription drugs. It lets many Americans obtain free birth control, mammograms and cholesterol tests. It requires many restaurants to post the calorie counts of their menu items. And it allows children to stay on their parents' health insurance plans until they turn 26”, says Luhby.

Obama and senior Democrats came out over the weekend to reassure people worried their coverage could be affected.

Many Republicans, on the other hand, were notably silent. Some have softened their tone towards a healthcare bill that has slowly gained support among the public in recent years.

Crucially, an “all-out assault on health care is one reason Democrats did so well in the midterm elections, as voters rejected anti-Obamacare candidates at the polls”, writes Farias