Law continued to shape health care in 2019 in courtrooms and legislatures around the country with developments that will reverberate in 2020 and beyond. Here are five of the most important.

1. Obamacare ruled unconstitutional

In December, the federal Fifth Circuit Court of Appeals affirmed a ruling that the individual mandate in the Affordable Care Act, often referred to as Obamacare, is unconstitutional. The court reasoned that since the mandate penalty was reduced to $0 by the Tax Cuts and Jobs Act of 2017, it is no longer a tax, so it no longer falls under the 2012 Supreme Court ruling that upheld it. The original ruling by Judge Reed O’Connor of the Northern District of Texas had further concluded that the mandate could not be severed from the rest of the ACA, so the entire law must be invalidated.

While the Fifth Circuit’s ruling affirmed that the mandate is unconstitutional, it did not invalidate the rest of the law. Instead, it remanded the case back to Judge O’Connor to “employ a finer-toothed comb...and conduct a more searching inquiry into which provisions of the ACA Congress intended to be inseverable from the individual mandate.” This decision leaves an uncertain future for the ACA. The Supreme Court may choose to hear the case quickly without a revised ruling from the Northern District of Texas, or it could wait for the “finer-toothed comb” opinion, which could leave the fate of the ACA undecided for years.

2. Pharmaceutical industry held accountable in the opioid epidemic

In August, an Oklahoma judge issued a ruling that ordered Johnson & Johnson to pay over $572 million as restitution for the company’s role in promoting the opioid epidemic there. The ruling prompted a nearly immediate offer from Purdue Pharma, the manufacturer of OxyContin, to settle more than 2,000 lawsuits for between $10 billion and $12 billion and a promise to file Chapter 11 bankruptcy, fulfilled in September.

In October, drug distributors McKesson, Cardinal Health, and AmerisourceBergen agreed to pay $215 million to settle a case brought against them by two Ohio counties alleging that they played a role in contributing to the epidemic. Later the same month, Teva, the Israeli drugmaker that made generic versions of opioids including OxyContin, proposed an approximately $23 billion settlement, offering to pay $250 million in cash and a donation of addiction-fighting drugs, including a generic version of Suboxone

3. The abortion debate intensified

During a six-month period in 2019, several states in the South and Midwest enacted 58 abortion restrictions with two of the most restrictive passed in Georgia and Alabama. Georgia’s Heartbeat Bill bans all abortions after six weeks of pregnancy, the point at which a doctor can usually detect a fetal heartbeat. The Alabama Human Life Protection Act permits abortions only to avoid a serious health risk to the mother, and if the fetus has a lethal anomaly.

By October, U.S. District Judge Steve Jones of the Northern District of Georgia had blocked the Heartbeat Law, and U.S. District Judge Myron H. Thompson of the Middle District of Alabama had blocked the Alabama Human Life Protection Act.

At the federal level, an anti-abortion rule created a difficult challenge for Planned Parenthood. In August, the organization announced that it would withdraw from Title X, the federal program that provides family planning services to low-income women, rather than comply with federal requirements attached to that funding that would have forbidden it to refer patients for abortions. Planned Parenthood, along with other similar organizations, challenged the rule in federal court, where U.S. District Court Judge Michael McShane issued a nationwide preliminary injunction on its enforcement that was stayed by the Ninth Circuit Court of Appeals.

4. Medicaid work requirements faced skepticism in court

In 2019, courts and the Trump administration continued to battle over work requirements for Medicaid recipients. Early in the year, Judge James E. Boasberg of the Federal District Court for the District of Columbia denied restrictions in both Kentucky and Arkansas that required Medicaid recipients to work or volunteer to be eligible for coverage. In his ruling, Boasberg found that Secretary of Health and Human Services Alex Azar’s approval of those requirements was “arbitrary and capricious.” The rulings did not deter the Trump administration, however, and by December, South Carolina had become the tenth state to seek to impose work requirements on Medicaid recipients.

5. New York State eliminated its religious exemption for vaccination

In June, New York became the fifth state to repeal all non-medical exemptions, striking the exemption used by parents of approximately 26,000 students up to age 18. The bill was introduced to combat an aggressive measles outbreak, the worst in 27 years, that resulted in more than 600 new cases in New York City in the previous year. The new law heightened the dispute between public health advocates and the vaccine skeptical. In November, a state judge ruled that it did not violate any constitutional rights to religious freedom and that the government had the right to mandate vaccination to protect public health.

Mara Smith is an associate general counsel for Brighton Health Plan Solutions, LLC, a third-party administrator and health plan management innovator operating on the East Coast.