One of the biggest cases the Supreme Court decided this term upheld a key provision of the Affordable Care Act (ACA). The King v Burwell ruling averted the possibility that Obamacare would be torpedoed by restrictions on insurance subsidies in states that had not established their own health insurance exchange.

When the opinion was released, ACA supporters outside the court chanted with jubilation that “The ACA is here to stay.”

They are probably right, but there is still a lot of work to be done to maintain recent gains and make further progress. The fight for health care reform is not over with the ruling in King v Burwell – nor should it be.

We have avoided a crisis, but issues about meaningful insurance coverage, access to health care and costs were problems before the ruling and are still problems today.

The fight over the ACA is not over

King v Burwell isn’t the first existential threat that the ACA has survived. Since the ACA was enacted in 2010, I have conducted nearly 200 interviews with policymakers about the politics of health reform. This has given me a view of the ACA’s implementation from the trenches.

In late 2012, after President Obama had just won reelection and the Supreme Court had upheld the individual mandate, a critical part of the ACA requiring individuals to have insurance, I wrote that “We can finally say with some certainty that the ACA is here to stay.”

But this time I am more cautious about predicting an end to the fighting over the ACA.

The Republican-controlled Congress will never successfully repeal the ACA as long as President Obama wields the veto pen. But what if a Republican occupies the White House in 2017?

Right now, it seems implausible that enough lawmakers would be willing to remove insurance from millions of Americans and reinstate health insurance policies that made it very difficult for people with preexisting conditions to obtain coverage.

But Republicans will continue to push for a full repeal over the next two years, including many of the two dozen candidates for the party’s presidential nomination. Most had press releases or tweets calling for repeal almost immediately after the Supreme Court decision was announced.

One contender, Senator Ted Cruz of Texas, responded that:

Every GOP candidate for the Republican nomination should know that this decision makes the 2016 election a referendum on the full repeal of Obamacare.

Keep working on Medicaid expansion

Right now, policymakers, scholars and advocates should continue focusing on expanding Medicaid. The program provides health care to people with low incomes.

Before the ACA was implemented, eligibility for this program had been historically limited to certain categories of people. How poor you had to be to qualify depended on whether you were a child, a pregnant woman or a parent. Childless adults generally could not qualify.

The ACA tried to change this by expanding Medicaid eligibility to everyone whose income is less than 138% of the federal poverty level. States technically were given the choice of whether or not to participate, but would lose all their Medicaid money if they refused. But in 2012, the Supreme Court decided that this was unconstitutionally coercive. That meant states could maintain their existing Medicaid program even if they refused to participate in the expansion.

To date, about 20 states still have not cooperated with this part of the law, preventing millions from receiving coverage and causing hospitals to swallow large costs from uncompensated care. This includes most of the South and states with large uninsured populations such as Florida and Texas.

An estimated 4.3 million more people would be insured if the remaining states expanded Medicaid.

With King v Burwell in the rear-view mirror, it looks like some states are considering expanding Medicaid. Utah is negotiating with the Obama administration about expansion. Alaska Governor Bill Walker is set to announce plans to expand Medicaid on July 15. Other states are developing plans for expansion.

Refusing to expand Medicaid is a missed opportunity for states and their hospitals. The federal government is initially paying 100% of the expansion costs (which will drop to 90% in 2020). This is substantially more than the average 57% it pays for the pre-ACA version of the program.

More people having coverage results in hospitals giving care to fewer people who will never be able to pay. In the places Medicaid has been expanded, uncompensated care costs in 2014 are estimated to be US$7.4 billion (21%) lower than they otherwise would have been.

An audience member takes the Pledge of Allegiance before the arrival of President Barack Obama at a town hall meeting on health insurance reform at Portsmouth High School in Portsmouth, New Hampshire, August 11 2009.

The ongoing fight for health reform

On July 1, less than a week after the recent Supreme Court decision, President Obama was in Tennessee to talk about what is next for health care reform in the United States. The president said:

I’m hoping that what we can do is now focus on how we can make it even better. Because it’s not as if we’ve solved all the problems in our health care system.

When the ACA passed in 2010, many progressives were severely disappointed. They felt that it did not do enough. The law introduces some delivery and payment reforms, but did little to directly tackle rising health care costs. Instead, the major focus was on expanding insurance coverage.

Future health reform efforts need to more fully address the fact that access to health insurance does not equal access to care. Not all doctors accept Medicaid, and large parts of the country have severe shortages of medical providers.

And for people who earn too much to qualify for Medicaid, high deductible plans might seem like an attractive option because their monthly premiums are low. However, high costs for care can make it harder for people to actually use their insurance.

We need to maintain the progress that has been made, with the uninsured rate dropping from 18% in mid-2013 to 11.4% in mid-2015. But it is also time to more fully confront that increasing access to care is not the only, or even the best, way to improve population health. When a major ACA program has faced financial challenges, the answer has been to take money from the part of the ACA that was intended to devote resources to preventative care.

Policymakers, scholars, and advocates need to focus more on public health, urban planning and initiatives that improve the conditions that people live, work and grow in (often called the social determinants of health). The ongoing fights over reform are an opportunity to move beyond thinking about health in terms of access to insurance and more toward finding ways to improve health overall.

David K Jones received funding from the Commonwealth Fund to conduct research about King v. Burwell.

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