Obamacare won this battle, but the administration is still fighting a war with states and with Congress.

By Kimberly Leonard 

The most recent attack designed to unravel President Barack Obama’s health care law has come to a close, with the Supreme Court ruling 6-3 to uphold low- and middle-income Americans’ ability to receive tax subsidies for health insurance regardless of the state in which they live. The celebrations of proponents of the Affordable Care Act, however, were tempered by the knowledge that the political fight over the law will continue, at both the state and federal level.

“The fight over Obamacare probably won’t ever end,” says David Jones, assistant professor of health policy and management at Boston University School of Public Health.

Republican members of Congress have vowed to repeal and replace the law, which they say is hurting Americans and making health care more expensive, and they renewed their commitment to roll back the reforms on Thursday. But some see the Supreme Court’s ruling as the end of serious legal attacks on the health care law.

“There will still be legal challenges, and political moves to alter the law, but the structure will remain,” Nancy Nielsen, a clinical professor at the University at Buffalo’s School of Medicine and Biomedical Sciences, said in a statement. “Everything was riding on this. Now the country and Congress can get serious about fixing the things in the law that need improvement.”

Advocates and opponents alike say portions of the law need to be addressed – including making health care better and less expensive, and looking at Medicaid expansion, a mandate in the health care law that the Supreme Court in 2012 ruled was optional for states.

Even Obama acknowledged during White House remarks after the high court delivered the King v. Burwell decision that more progress needs to be made, particularly with regard to Medicaid, for the law to function as it was intended.

“I’m going to work as hard as I can to convince more governors and state legislatures to take advantage of the law, put politics aside, and expand Medicaid and cover their citizens,” he said.  

The theme was echoed by Health and Human Services Secretary Sylvia Burwell, who said in a statement that Americans want affordable access to quality coverage as well as a “health care system that improves the quality of care and spends our dollars more wisely.”

Some medical groups have already identified areas in which Obamacare could be improved. Following the ruling, the American Association of Neurological Surgeons and Congress of Neurological Surgeons sent a list of enhancements they said would “fix the shortcomings of the law,” including allowing consumers more choice in their health plan benefits and tackling health care costs.  

Thursday’s case centered on whether plaintiffs’ arguments that middle- and low-income adults who purchased health insurance through the federally run Healthcare.gov marketplace were entitled to subsidies based on the language of the law that says tax credits are only to be distributed for online marketplaces “established by the state.”

The law’s architects countered that subsidies were always meant to be distributed through both channels, and that the goal of the law was to cover all Americans. The Supreme Court agreed, nevertheless noting that the wording is “ambiguous.”

“The Affordable Care Act contains more than a few examples of inartful drafting,” Chief Justice Roberts wrote in the majority opinion.

Proponents of the law lingered on the steps of the Supreme Court after the ruling, cheering “The ACA is here to stay” and “POTUS, SCOTUS, we love them all,” while holding signs that showed how many people were still covered as a result of the ruling.  

Had the court ruled in favor of the plaintiffs, administration projections showed that 6.4 million Americans would lose health insurance because they no longer would be able to afford it.

“There was clear recognition that the Congress wouldn’t have written the law to destroy subsidies versus trying to help them,” says Elizabeth Wydra, chief counsel for the Constitutional Accountability Center, which filed an amicus brief that supported the administration’s position.

But the decision was a major blow to groups that oppose the Affordable Care Act. Sally Pipes, president of the Pacific Research Institute, says she had been optimistic that the decision would go the other way.

“I’m very disappointed. Many of us rely on the court to save us all from out-of-control modern government, and that’s not the way it is anymore,” she says.

Her assessment is that Roberts and Justice Anthony Kennedy did not want to face the backlash of what would happen if they ruled subsidies invalid when they are distributed through the federal exchange.

One less-discussed outcome that could emerge from the case is that some of the 16 states and the District of Columbia which established their own exchanges may decide to chuck them in favor of having their residents use the federal exchange.

“I think a lot of states are asking that question: ‘Why would we want to take control over this?’ They have to take into account money and political capital and the major administrative headache,” Jones says.

Ralph Tyler, a former insurance commissioner for the state of Maryland who is now a partner at Venable LLP, agrees. “There will be states that will abandon their own exchanges and move in the direction of the federal exchange,” he says. Though there are advantages to having state exchanges – such as making it more accessible to state residents and tailoring it to local needs and expectations – states have faced challenges in establishing their own exchanges, including technical glitches and long wait times that frustrated consumers or delayed their enrollment.

“I think some states will get out of the business now that there isn’t a risk to the subsidies,” he says.

Jones points out that state exchanges do have some advantages, by allowing control over regulating the insurance market and setting the fee that consumers pay. Some state leaders have grumbled to him that they are frustrated because they wanted states to take as much control as possible, but now feel that the federal government is slowly taking that power back.

Gerry Wedig, associate professor of business administration from Simon Business School at the University of Rochester, says he doesn’t expect states to give up their exchanges.

“They have a bit more decision power about some of the parameters of how the exchanges are run,” he says.

Following the Supreme Court ruling, some groups expressed their frustrations about continual attacks on the law. “It’s past time for Republicans – whether in Congress or the state capitals – to end their repetitive efforts to repeal or damage the Affordable Care Act,” Richard Trumka, president of the AFL-CIO, said in a statement.

Neera Tanden, president of the left-leaning Center for American Progress, said in a statement that the case “should be the final nail in the coffin of repeal by legislative and judicial means from opponents of the ACA.”  

Responses from conservative groups, however, appear to indicate that is not the plan. “The Supreme Court ruling does not fix Obamacare,” Nina Owcharenko, director of the Center for Health Policy Studies at the conservative Heritage Foundation, said in a statement. “The only fix to Obamacare is its repeal.”

Says Jones: “Now we can go back to the regular fights we were having.”