A Texas judge’s stunning declaration that Obamacare is unconstitutional not only kneecaps the health care law, it would also cripple President Donald Trump’s entire health care agenda.

Trump wants lower drug prices, drastic action on the opioid crisis and protection for people with pre-existing conditions. Those are the parts of the law many Republicans do want to keep, but with the entire law invalidated — pending appeal — Trump and Republicans are trying to figure out how to live with a judicial ruling they kind of wanted, but didn’t want in such a big way.

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The blunt force of the Texas ruling, without consideration for the dozens of popular provisions sprinkled throughout the law, shows just how intertwined the Affordable Care Act has become as part of the American health care system.

And nobody on the Republican side has a clear plan on what to do now.

Nothing is changing yet. But if the ruling does stand following appeals, or if the Trump administration reverses course and refuses to enforce more parts of the law, because of the Texas case, seniors would immediately be on the hook for thousands of dollars in additional drug spending. Millions of Americans would lose Medicaid coverage — the largest payer of addiction treatment in the country.

Meanwhile, the administration would also lose access to a powerful weapon for reforming the U.S. health system — the CMS Innovation Center. Created by the health law, it gives the government broad powers to test new health policies, whether it be doctor payment models or new cancer drug pricing ideas, and scale them up nationally without congressional approval.

Trump cheered the Friday federal court ruling that the entire Affordable Care Act is unconstitutional. “Great news for America!” he tweeted.

But without Obama’s signature law, the Trump administration would be left scrambling to achieve its health care goals, while simultaneously dealing with a system thrust into chaos.

Trump’s health department has identified four main priorities: lowering the cost of prescription drugs, ending the opioid crisis, improving health insurance’s availability and affordability, and moving the health system to one that pays for the quality of services offered, not the quantity. And even as the Trump administration bashes the ACA, it’s leaning hard on it to accomplish these goals.

The court’s decision “is a cloud over the efforts to keep moving forward on health reforms and it’s going to create confusion and probably delay,” said John Rother, president and CEO of the National Coalition on Health Care, adding, “Now I wonder how we’re going to be able to keep up the momentum” on issues such as drug pricing and payment reform.

“The breadth of the act is extraordinarily sweeping, and it will affect every aspect of the health system if it’s struck down, including many things this administration has publicly championed or made priorities,” said Rachel Sachs, a health policy expert and law professor at Washington University in St. Louis.

Without Obamacare, Americans would see drug spending go up with seniors and state governments taking the brunt of the blow.

It’s the exact opposite of Trump’s extensive blueprint on lowering drug prices. The goal, the president said in May, is to take “the most sweeping action in history to lower the price of prescription drugs for the American people.”

Without Obamacare, many seniors would likely spend around $2,000 or more in out-of-pocket drug costs each year, said Juliette Cubanski, associate director of Medicare policy at the Kaiser Family Foundation. That’s because the ACA required drugmakers to provide big discounts to seniors in the coverage gap phase of their Medicare Part D benefit. In 2016, more than 5 million Medicare recipients reached the coverage gap, with drugmakers providing $5.7 billion in discounts to offset the costs of their medicines, Cubanski said.

States’ Medicaid programs, which are a big part of state budgets, would also take a hit because drug companies could go back to giving them the smaller pre-Obamacare discounts on medications, and these discounts wouldn’t apply to Medicaid managed care programs.

Meanwhile, the biosimilar market, which Trump’s FDA chief, Scott Gottlieb, has spent months trying to invigorate and improve, would collapse as Obamacare established the pathway to bring cheaper versions of biologic medicines to patients. Those drugs are often the most expensive medicines in the U.S.

“As if it’s not challenging enough already for biosimilars to get approved and actually come to market in this country, this would make it even more challenging,” Cubanski said.

At the same time, Trump’s HHS would have a much more difficult time implementing its new ideas to lower the cost of medicines, like an October plan to tie the cost of physician-administered drugs — things like chemotherapy or other infused medications — in Medicare to the lower prices paid by other developed countries.

Without Obamacare’s Innovation Center, Trump would likely need congressional approval to implement such a sweeping national test on drug prices — a long shot given recent skepticism from his own party, the drug industry, and patient and doctor groups.

The Innovation Center is also a key component of the Trump administration’s plan to move the health system away from paying for the sheer number of services provided, and instead incentivize good care — and it could unveil new projects as soon as the first three months of 2019.

HHS Secretary Alex Azar teased their release, saying on Wednesday that “the biggest things that we’re going to be launching, coming soon, are going to be these demonstrations that Adam Boehler — our head of the Center for Medicare and Medicaid Innovation — has been working on.”

“There’s a lot of basic payment plumbing in the ACA. Ripping it out would be enormously disruptive,” Nicholas Bagley, a professor of law at the University of Michigan Law School, wrote in an email.

Doctors and hospitals are still committed to the payment reform effort, several sources told POLITICO, as they’ve already devoted ample time, money and resources into moving toward value-based care. CMMI projects have been underway for years, so eliminating the center would, as Bagley put it, still be an “enormous procedural headache.”

There is a possibility that a higher court could keep parts of the health law, such as CMMI, but rule other parts of Obamacare invalid, like the popular protections for pre-existing conditions. While the Trump administration has committed to ensuring those people would still have health coverage, it hasn’t offered any suggestions on how to preserve those protections in a concrete way without Obamacare — which Democrats capitalized on during the midterm elections.

On the opioid front, Trump has repeatedly promised to end the scourge of addiction. But experts say any rollback in Medicaid coverage, the biggest payer of behavioral health care, would almost certainly set back his efforts to address the crisis killing 115 Americans every day.

The administration and Congress have invested billions to expand access to treatment, but work funded by those grants would likely be dwarfed by coverage losses if Medicaid expansion goes away under Friday’s ruling. Roughly 1.2. million people with addiction and mental health issues are covered under Medicaid expansion.

Medicaid is the “bedrock” of addiction treatment, said Andrew Kessler, founder of Slingshot Solutions, a consulting firm specializing in behavioral health. “You can’t do a single thing to inhibit Medicaid If you say you want to see improvement in substance use disorder treatment. The two don’t go together.”

Advocates say scrapping the law would also be harmful to the tens of thousands of people in the private insurance market seeking help for drug addiction, since Obamacare requires insurers to cover treatment as part of 10 essential health benefits.

“Any backtracking on this would be a significant blow to patients,” said Mark Covall, president and CEO of the National Association for Behavioral Healthcare.

For decades, California has been an afterthought in determining presidential elections. But that’s about to change.

The nation’s most populous state, long a reliable fountain of campaign cash but not a force in selecting who sits in the White House, is casting a long shadow over the 2020 Democratic presidential primary. At least four Californians are nearing decisions on whether to run, and the state’s early, Super Tuesday primary seems certain to heavily influence the trajectory of the nomination fight.

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“California is tired of being the nation’s ATM,” said Kevin de León, a Democratic legislative leader who fell short in his challenge to Sen. Dianne Feinstein this year. “As the fifth-largest economy in the world, Californians deserve to have a voice on selecting the next president.”

Anticipation that this election will be different, providing California with national clout commensurate with its size, coincides with the state’s role as a beachhead for the anti-Trump resistance. It’s fueled by perceptions both inside and outside the state that California’s brand of unapologetic progressivism has moved into the mainstream of the party after years of being dismissed nationally as a zany laboratory for far-left dreamers.

“A lot of it is the sense and the feeling that Trump is vulnerable,” said Chris Wicker, a Democratic National Committee member from Nevada.

The state’s move up the calendar to March 3 has already forced Democratic presidential contenders to adapt. Aides to prospective candidates said they are plotting strategies to address the glut of delegates awarded by California, including pairing early trips out West to Nevada, which holds its caucuses on Feb. 22, with California stops.

Some are discussing Latino-focused outreach that includes frequent stops in Texas, another Super Tuesday state that may field outgoing Rep. Beto O’Rourke and former Obama HUD Secretary Julian Castro.

“For the first time in a major way, Latinos have a real opportunity to play a huge role in deciding early who the Democratic nominee will be,” de León said of the early maneuvering. “Midwest and East Coast candidates will be forced to brush up on their high school Spanish very quickly. West Coast and Southwestern candidates can have an advantage if they play it right — but it’s not automatic.”

The four homegrown, would-be candidates — Democrats Sen. Kamala Harris, Los Angeles Mayor Eric Garcetti, billionaire impeachment and climate activist Tom Steyer, and Rep. Eric Swalwell — also stand to shape the early contours of the primary.

Harris and Garcetti have teams in place familiar with the state’s uniquely complicated politics. Harris, still in her first term in the Senate, has seen her popularity steadily improve since her upset victory for attorney general in 2010. The political consulting firm that works with her recently brought on top strategist and organizer Laphonza Butler, who has been instrumental in marshaling boots on the ground for the state’s largest labor union.

Garcetti, who in his reelection last year earned more than 80 percent of the vote against 10 candidates, has strong ties with California donors. He’s raised money for himself and local ballot initiatives on transportation and infrastructure, but he’s also serving as a conduit for other state Democratic parties and officials looking to tap into California cash. If he runs, the mayor will base his presidential campaign out of Los Angeles, according to a person familiar with his planning, giving him a foothold in one of the nation’s most expensive media markets.

Several Democrats cautioned that the home-field advantage for the California-based candidates will be limited – they still have to perform well in the early contests and establish themselves as presidential material. As a point of reference, Democrats cite Donald Trump’s resounding victory over Sen. Marco Rubio in Florida in 2016, which finished Rubio after the senator failed to win any of the four early states — Iowa, New Hampshire, South Carolina and Nevada.

“None of these candidates have a Jerry Brown-stature lock on the state,” one rival Democratic strategist said.

Nor do they have a lock on the state’s big-name donors, said another top aide to a probable candidate, who expects those donors to continue showering money on multiple candidates, at least until the field winnows and leaders emerge.

While the high cost of campaigning in California, combined with its proportional awarding of delegates, will favor better-known candidates, it could also propel a surprise winner from Iowa or New Hampshire.

“California is going to be the place where only the top-tier three or four contenders can play and the only alternative is if a dark horse emerges from Iowa or New Hampshire — and then starts raising money to play there,” said Ben Tulchin, a Democratic pollster on Bernie Sanders’ 2016 presidential campaign.

Still, there’s considerable uncertainty about what impact the early state outcomes might have on the California electorate — or vice versa.

Mail ballots will go out in California just as Iowa Democrats caucus in early February. And Californians will be voting by mail even before New Hampshire’s primary — though that could change should Granite State officials accelerate the date. Given California’s early balloting, “that momentum from earlier states will show up right away,” said Bill Burton, a California-based Democratic consultant and a Barack Obama campaign alum.

On the flip side, late-arriving California ballots counted weeks after Election Day — votes that have historically favored progressives — could rob the eventual winner of the instant momentum of a mega-state win.

Out-of-state Democrats contemplating competing in California have spent years laying the groundwork. Cory Booker, the New Jersey senator who attended college at Stanford, has been traveling to the state to campaign and raise money since he was mayor of Newark. Sen. Elizabeth Warren was a top surrogate for Harris when she ran in 2016 and, between glitzy fundraising events of her own, appeared in Orange County this year to raise money for her former law student, Katie Porter, who won a House seat there.

Former Vice President Joe Biden headlined a fall fundraiser for Feinstein hosted by billionaire philanthropist Eli Broad and his wife Edy and an event of his own with Hollywood heavy-hitters.

Bernie Sanders has even run a full-blown campaign there, barnstorming the state during his 2016 run, stumping in distant corners that seldom receive visits from presidential hopefuls. He also waded into the debate over statewide ballot initiatives and raised far more money and in 2016 raised far more money from California residents — $17.1 million — than he did from his second-highest state, New York. More recently, he stumped for state legislation, headlined a nurses union convention and starred in an October get-out-the vote rally with East Bay Rep. Barbara Lee.

California’s robust progressive streak puts Sanders on friendly terrain with its receptiveness toward issues he helped elevate in the national debate — including government-run healthcare and free community college.

A strong majority of likely statewide voters, 57 percent — and a whopping 80 percent of Democratic likely voters — say universal health coverage should be a very high or high priority for the state’s incoming leaders, according to a new Public Policy Institute of California poll.

Nearly two-thirds of Democratic likely voters say tuition-free community college should be a very high or high priority, the PPIC survey found.

“An early California primary on Super Tuesday will require people to not just take positions on issues like health care, climate change, student debt, and racial justice, but describe clearly our ability to lead on such progressive priorities,” Steyer, who held a town-hall style meeting in Fresno on Thursday, told POLITICO. “We are no longer an afterthought in the presidential nomination process — we are a rightfully crucial piece to shaping the direction of our party and our nation.”