The Affordable Care Act, upheld in a decisive 6-3 Supreme Court ruling Thursday, is now virtually assured of surviving as a permanent feature of the American healthcare system.
Republicans' chances of repealing the law, which provides health coverage to more than 20 million Americans, all but evaporated after the strongly worded decision written by Chief Justice John G. Roberts Jr.
It was the second time in three years that the high court had turned aside a legal threat to the law, one of President Obama's signature achievements.
With no serious Republican alternatives and a historic expansion in medical coverage well underway, Obamacare is about as firmly ensconced as a new law can be in a politically divided country.
The ruling came in a lawsuit that had threatened to strip insurance subsidies from more than 6 million Americans in at least 34 states.
The law's wording was at times “inartful,” the majority said, but Congress clearly intended for the aid for low- and moderate-income Americans to be available everywhere. The justices rejected claims from the challengers that a handful of words in the statute made subsidies available only in a few states.
“We must read the words in their context,” the chief justice wrote.
In the decision, Roberts also explicitly blessed the law's sweeping system for guaranteeing coverage, noting that the model, pioneered in Massachusetts, had accomplished what other attempts to extend
insurance protections to Americans had not.
“The Affordable Care Act adopts a version of the … reforms that made the Massachusetts system a success,” he wrote.
Congressional Republicans, meanwhile, still have no plan to replace the law enacted more than five years ago.
Speaking to reporters after the court's decision, House Speaker John A. Boehner (R-Ohio) repeatedly refused to commit to any new strategy to repeal or revise the health law.
And across the country, as millions of previously uninsured Americansh ave gained coverage, a growing number of Republican governors are signaling their interest in moving on.
Still, political battles over the law won't end anytime soon.
In the presidential campaign, Republican hopefuls need to appeal to conservative voters — many of whom deeply dislike the law and the president who championed it. That guarantees that cries for repeal will remain prominent, particularly during next year's primaries.
“This is not the end of the fight,” former Florida Gov. Jeb Bush said Thursday. “We need to repeal and replace Obamacare.”
Nearly all of the other major candidates for the nomination echoed Bush's statement.
But away from the campaign trail, implementation of the law and its coverage expansion will continue.
“We appreciate that the deep uncertainty of this issue has been resolved,” Michigan Gov. Rick Snyder, a Republican, said Thursday after the court issued its decision. “The health and well-being of the people of Michigan is always a top priority.”
In his state, more than 200,000 low- and moderate-income residents stood to lose insurance assistance if the court backed the challengers, who argued that no subsidies should be available in any state that did not establish its own insurance marketplace through the law.
Michigan is one of the 34 states that instead deferred to the federal HealthCare.gov marketplace.
Like many other Republican governors, Snyder has been more focused on expanding access to healthcare than continuing the battle over the law.
Michigan is working to secure approval from the Obama administration for further changes to the state's Medicaid program, which was expanded under the law to guarantee coverage to the poorest residents.
Michigan is one of 29 states that have accepted federal aid in the law to broaden Medicaid coverage — a number that has steadily grown over the last several years to include even very conservative states such as Indiana.
In the last two years, some 11 million people have newly enrolled in Medicaid, mostly in states that expanded their programs.
An additional 10 million Americans, many of them previously uninsured, now get health coverage through marketplaces created by the law.
That has fueled a historic coverage expansion. In the first quarter of this year, 11.9% of adults in the U.S. lacked insurance, down from 18% in the third quarter of 2013, before the current expansion began, according to Gallup.
And more red states, including Utah, Tennessee and Wyoming, have been exploring ways to expand Medicaid coverage.
In Washington, by contrast, GOP congressional leaders kept up their criticism of the law.
“Republicans are ready to reduce the cost of healthcare so more people can afford it, put patients back in charge, and restore freedom and choice to the healthcare market,” said Senate Health Committee Chairman Lamar Alexander (R-Tenn.).
But it is unlikely there will be significant new legislation, at least until after next year's presidential election.
To date, Alexander and most other congressional Republicans have offered little more than general outlines rather than real legislation that would fulfill such promises.
Several GOP blueprints even incorporate key protections from the current law, including guaranteeing coverage and providing government assistance to help consumers purchase insurance.
On the other side of the debate, supporters of the health law redoubled their calls on Republicans to stop fighting.
“It's time for people on both sides of the aisle to accept that the law is working and take important steps to fully implement it,” said Sue Berkowitz, head of South Carolina Appleseed Legal Justice Center, a nonprofit that has been working to expand coverage in that state despite Republican officials' resistance to Medicaid expansion.
The president joined the chorus, speaking from the White House Rose Garden on Thursday afternoon.
“The Affordable Care Act is here to stay,” he said.