The Affordable Care Act has been challenged in court almost continuously since it was signed in 2010, and the major Affordable Care Act rulings have consistently left the law’s core intact while reshaping its edges. The Supreme Court has heard three existential challenges to the statute and one significant challenge to its preventive care requirements; each time, the law survived. What has changed the ACA most in recent years is not a courtroom loss but the expiration of enhanced subsidies, a 2025 reconciliation law, and a federal rule now being fought over in two district courts.
NFIB v. Sebelius (2012)
The first case to reach the Supreme Court was National Federation of Independent Business v. Sebelius. Opponents argued the individual mandate, which required most Americans to carry insurance or pay a penalty, exceeded Congress’s power under the Commerce Clause. Five justices agreed with that argument, concluding that Congress cannot compel people to enter a market it wants to regulate.1Justia US Supreme Court. National Federation of Independent Business v. Sebelius, 567 U.S. 519
Chief Justice John Roberts then saved the mandate on a different theory. Joined by Justices Ginsburg, Breyer, Sotomayor, and Kagan, he held that the penalty functioned as a tax the IRS collected, and Congress had the constitutional authority to impose it. The vote to uphold was 5–4.1Justia US Supreme Court. National Federation of Independent Business v. Sebelius, 567 U.S. 519
The same decision reshaped the ACA’s Medicaid expansion. Congress had designed the expansion to cover all adults under 133 percent of the federal poverty level and threatened to strip states of their existing Medicaid funding if they refused. By a 7–2 vote, the Court found that threat unconstitutionally coercive, calling it “economic dragooning that leaves the States with no real option but to acquiesce.”1Justia US Supreme Court. National Federation of Independent Business v. Sebelius, 567 U.S. 519 The remedy severed the penalty: the federal government could still offer expansion funding, but it could not pull existing Medicaid dollars from states that declined. Expansion became optional.
As of March 2026, 41 states and the District of Columbia have adopted the expansion. Ten states, including Texas, Florida, and Georgia, have not.2KFF. Status of State Medicaid Expansion Decisions
King v. Burwell (2015)
The second Supreme Court challenge targeted the premium tax credits that make marketplace coverage affordable. A provision of the ACA described those credits as available on “an Exchange established by the State,” and roughly two-thirds of states had declined to build their own exchanges, relying instead on HealthCare.gov. The plaintiffs in King v. Burwell argued that people in those states could not receive subsidies.
On June 25, 2015, the Court ruled 6–3 that the credits were available regardless of who operated the exchange. Chief Justice Roberts, again writing for the majority, found the phrase ambiguous when read against the rest of the statute. Limiting subsidies to state-run exchanges would destabilize insurance markets and undermine the law’s “interlocking reforms,” an outcome he concluded Congress could not plausibly have intended.3Justia US Supreme Court. King v. Burwell, 576 U.S. 473 Justice Scalia, joined by Thomas and Alito, dissented, arguing the plain text should have controlled.4Oyez. King v. Burwell
The ruling preserved subsidies for an estimated five to six million people across 34 states.3Justia US Supreme Court. King v. Burwell, 576 U.S. 473
California v. Texas (2021)
In December 2017, Congress passed the Tax Cuts and Jobs Act, which set the individual mandate penalty to $0 effective January 2019.5Commonwealth Fund. Eliminating the Individual Mandate Penalty The mandate itself remained on the books, but there was no financial consequence for going without coverage. That change created a new legal theory: if the mandate had survived in 2012 only because its penalty functioned as a tax, could it still be constitutional at $0?
Texas and other Republican-led states brought that argument. In December 2018, Judge Reed O’Connor of the Northern District of Texas ruled the mandate unconstitutional without a tax and declared the entire ACA inseverable, meaning the whole law had to fall.6California HealthCare Foundation. What the Texas v. Azar Ruling Means for the ACA and Health Coverage The Fifth Circuit affirmed the unconstitutionality finding in December 2019 but sent the severability question back for more analysis.7U.S. Court of Appeals for the Fifth Circuit. Texas v. United States, No. 19-10011
The Supreme Court took the case as California v. Texas. On June 17, 2021, it dismissed the suit 7–2 without deciding the constitutional question. Justice Breyer, writing for a majority that included Roberts, Thomas, Sotomayor, Kagan, Kavanaugh, and Barrett, held that no plaintiff had standing. Because the penalty had been zeroed out, the mandate was “textually unenforceable,” and neither the individual challengers nor the state plaintiffs could show a concrete injury traceable to it.8Supreme Court of the United States. California v. Texas, 593 U.S. ___ Justice Alito, joined by Gorsuch, dissented.9Oyez. California v. Texas
Hobby Lobby and Little Sisters of the Poor
A separate line of cases attacked the ACA’s requirement that employer health plans cover contraception without cost-sharing. In Burwell v. Hobby Lobby Stores, decided 5–4 on June 30, 2014, Justice Alito’s majority held that closely held for-profit corporations count as “persons” under the Religious Freedom Restoration Act and that the contraceptive mandate imposed a substantial burden on owners with sincere religious objections. The mandate failed RFRA’s least-restrictive-means test because the government had already built an accommodation for religious nonprofits that could be extended to for-profits.10Justia US Supreme Court. Burwell v. Hobby Lobby Stores, 573 U.S. 682 The ruling was limited to the contraceptive mandate and did not create a general religious exemption from insurance requirements.11Oyez. Burwell v. Hobby Lobby Stores
How far those exemptions could extend came back in Little Sisters of the Poor v. Pennsylvania, decided 7–2 in 2020. The Trump administration had issued rules creating broad religious and moral exemptions from the contraceptive mandate, and several states sued. Justice Thomas’s majority opinion held that the ACA granted federal agencies broad discretion to define preventive care requirements and, by extension, to write exemptions. The Court also rejected claims that the rulemaking violated the Administrative Procedure Act.12Supreme Court of the United States. Little Sisters of the Poor v. Pennsylvania, 591 U.S. ___ Justice Ginsburg, in dissent, warned that tens of thousands of women would lose access to no-cost contraception.13Oyez. Little Sisters of the Poor v. Pennsylvania
Kennedy v. Braidwood Management (2025)
The most recent Supreme Court ruling came on June 27, 2025. In Kennedy v. Braidwood Management, decided 6–3, the Court upheld the ACA’s requirement that insurers cover preventive services rated “A” or “B” by the U.S. Preventive Services Task Force without cost-sharing. The plaintiffs, led by a Texas-based business, argued that Task Force members are “principal officers” who under the Appointments Clause must be nominated by the president and confirmed by the Senate, not appointed by the HHS Secretary.
Justice Kavanaugh’s majority opinion rejected the argument, treating Task Force members as inferior officers whose work the Secretary directs and supervises. Two features drove the conclusion. The Secretary can remove Task Force members at will because no statute grants them for-cause protection. And the Secretary can review and block Task Force recommendations during a mandatory waiting period of at least one year before they become binding. A statutory description of Task Force members as “independent” did not insulate them from the Secretary’s oversight; the Court read the word as a directive against undue outside professional influence.14Supreme Court of the United States. Kennedy v. Braidwood Management, 606 U.S. ___ Justice Thomas, joined by Alito and Gorsuch, dissented.15SCOTUSblog. Kennedy v. Braidwood Management
The ruling was narrow. It addressed only the Task Force’s constitutional structure and did not resolve separate claims about the Advisory Committee on Immunization Practices or the Health Resources and Services Administration. Those questions returned to the federal district court for briefing on whether the HHS Secretary’s ratification of ACIP and HRSA recommendations complies with the Administrative Procedure Act.16KFF. Kennedy v. Braidwood: The Supreme Court Upheld ACA Preventive Services, but That’s Not the End of the Story The plaintiffs’ religious freedom claims regarding PrEP coverage, which had prevailed at the district court, also remain unresolved.17KFF. Explaining Litigation Challenging the ACA’s Preventive Services Requirements
Where the ACA Stands in 2025 and 2026
Court wins have not settled the ACA’s practical footprint. The enhanced premium tax credits enacted by the American Rescue Plan Act in 2021 and extended by the Inflation Reduction Act expired at the end of 2025 after Congress did not pass an extension.18ASTHO. ACA Enhanced Premium Tax Credits: Legislative Developments Marketplace plan selections fell from roughly 24.3 million in 2025 to 23.1 million in 2026,19KFF. Open Enrollment Marketplace Plan Selections and analysts project that effectuated enrollment could drop to about 17.5 million, a decline of nearly five million from the prior year.20KFF. What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles Average monthly premiums for marketplace enrollees rose 58 percent, and insurers filed median rate increases of 18 percent for 2026, the largest requested rate change since 2018.21Peterson-KFF Health System Tracker. How Much and Why ACA Marketplace Premiums Are Going Up in 2026
The Budget Reconciliation Law (H.R. 1)
H.R. 1, sometimes called the “One Big Beautiful Bill Act,” cleared the Senate 51–50 on July 1, 2025, with Vice President Vance casting the tiebreaking vote, and passed the House 218–214 two days later. It was signed into law on July 4, 2025.22Georgetown University Center for Children and Families. Medicaid, CHIP, and ACA Marketplace Cuts in the Budget Reconciliation Law Explained The law imposed federal work reporting requirements on Medicaid expansion enrollees and barred individuals who lose Medicaid for failing those requirements from receiving marketplace premium tax credits.23KFF. A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law The Congressional Budget Office estimated that the Medicaid work requirements alone would increase the uninsured population by 4.8 million by 2034, with the law’s marketplace-related provisions cutting federal marketplace spending by $213 billion over a decade.
The Marketplace Integrity Rule and the Two Lawsuits Over It
In June 2025, the Centers for Medicare and Medicaid Services finalized the “Marketplace Integrity and Affordability Rule,” which tightened eligibility verification, shortened enrollment periods, ended a special enrollment period for low-income consumers, allowed insurers to condition enrollment on repayment of past-due premiums, and redefined “lawfully present” to exclude DACA recipients from marketplace coverage.24Georgetown University Center on Health Insurance Reforms. The Dismantling of Obamacare Starts August 25 Unless Litigation Can Stop It CMS estimated the rule could cause up to 1.8 million people to lose coverage.25Becker’s Payer Issues. Judge Denies 21 States’ Bid to Halt New ACA Restrictions
Two lawsuits followed. In City of Columbus v. Kennedy, filed in Maryland federal court by cities and nonprofits, Judge Brendan Hurson on August 22, 2025, issued a nationwide stay blocking several key provisions, including the $5 monthly premium penalty on automatic re-enrollees, the revocation of guaranteed-issue coverage for those with unpaid premiums, and heightened income and eligibility verification requirements.26Thomson Reuters Tax & Accounting. Court Delays Key Provisions of Marketplace Integrity Regulations The judge found the plaintiffs had a “strong likelihood” of success on the merits and would face irreparable harm if the provisions took effect.27Georgetown University Center on Health Insurance Reforms. Ruling in Challenge to Marketplace Rule: Initial Analysis and Implications for States
The second suit, State of California v. Kennedy, was filed in Massachusetts by a 21-state coalition led by California Attorney General Rob Bonta and raised similar claims that the rule was arbitrary and capricious and exceeded CMS’s authority.28Courthouse News Service. RFK Jr. Faces 21-State Lawsuit Over Rule Gutting Affordable Care Act Coverage On October 1, 2025, Judge Nathaniel Gorton denied the states’ request for a preliminary injunction, finding they had not shown imminent irreparable harm.25Becker’s Payer Issues. Judge Denies 21 States’ Bid to Halt New ACA Restrictions Cross-motions for summary judgment were pending as of mid-2026.29Georgetown Law Litigation Tracker. State of California et al. v. Kennedy et al.
The Maryland injunction has kept several of the rule’s most aggressive provisions on hold. Other elements, including the exclusion of DACA recipients and changes to cost-sharing calculations, have moved forward. Both cases remain active.