The cast of characters working either to overturn or defend the Affordable Care Act in federal court continues to evolve and expand. More states are intervening to join the legal effort in the ACA’s defense, two states are rethinking their effort to overturn the law, and a sweeping array of state and national hospital associations, medical groups, consumers, and even the insurance industry are joining the fray.

Back in December, U.S. District Judge Reed O’Connor declared the entire ACA invalid, as a Texas-led coalition of plaintiff states had requested. In late March, the Trump Administration stunned legal observers when it announced that, far from its previous position of wanting to overturn the part of the ACA that protects people with pre-existing conditions, it is now seeking to have the entire law overturned.

That announcement seemed to launch the litigation into overdrive. On Monday, April 1, the Republican attorneys general in Montana and Ohio filed briefs arguing that a U.S. district judge in Texas erred in concluding that the entire ACA must be struck down because the law’s individual mandate is unconstitutional and cannot be severed from the rest of the law.

The two state officials oppose the requirement to purchase coverage, but argue that the rest of the law should be allowed to stand. They warn of disastrous consequences to people in their states if it is overturned.

“The fact that a ruling has negative consequences does not mean it is wrong,” argue Attorneys General Dave Yost of Ohio and Timothy Fox of Montana. “Let justice be done, though the heavens may fall. But the District Court’s ruling is wrong, and its errors threaten harm to millions of people in the Buckeye and Treasure states.”

Meanwhile, one state that was part of the original lawsuit – Maine – has filed a motion asking for permission to withdraw, and another state — Wisconsin – is considering following suit. And four states – Colorado, Iowa, Michigan, and Nevada – have been granted permission to join the litigation in defense of the ACA. These developments, linked to changes in the political composition of many states’ executive branches after the November 2018 elections, mean that the states defending the ACA now outnumber the states who wish it overturned.

Finally, also on Monday, April 1, the nation’s largest hospital associations and 24 state hospital associations filed a joint amicus brief urging the 5^th Circuit Court of Appeals to reject the Texas court’s “judicial repeal” of the ACA. “If upheld, it will unwind eight years of progress under the ACA’s broad set of reforms,” states the brief, submitted by the American Hospital Association, Federation of American Hospitals, the Catholic Health Association of the United States, and the Association of American Medical Colleges. “And if upheld, it will cause tens of millions of patients to lose their health insurance, returning them to the ranks of the long-term uninsured and putting their health at risk.”

The joint brief was quickly joined by a slew of other pro-ACA amicus briefs filed on the same day by groups representing doctors, insurers, hospitals, consumers, cities and counties, and including such groups as the American Medical Association, the American Cancer Society, AARP and the pro-industry American Health Insurance Plans.

So what’s next for the ACA litigation? The Trump Administration has until March 25 to file its intervening brief in the case. Plaintiffs’ response will be due on April 24, and reply briefs will then be due on May 15. All of this means that oral arguments before the 5^th Circuit will not be held until the summer at the earliest. A ruling could come in the fall – or be pushed into 2020 – and only then would the litigation be ripe for U.S. Supreme Court consideration.

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