The embattled Patient Protection and Affordable Care Act of 2010 (ACA) has endured years of existential threats. From the Supreme Court’s piercing NFIB v. Sebelius decision in 2012, to blocked funding from an unfriendly Congress, to the administrative changes from the Trump administration, and finally through a summer of repeal and replace proposals, the ACA has been politically battered and fundamentally reshaped. These changes have hindered its cost control efforts, and, consequently, policy-based inroads initially mandated by the ACA—most notably, attempts at both shrinking cost-shifting and growing the leverage of payers in the system—have been blunted and neutralized. Most notably, the NFIB case—the subject of this symposium—wounded the ACA’s efforts that were intended to truly bend the cost curve in American health care. This, from a health policy perspective, is the enduring legacy of that case. As a result, because the ACA is unable to adequately address America’s health care cost control problem, it remains politically vulnerable. And without a commitment to policy-based solutions that address the cost of American health care, any reform solutions—whether they be contained within the ACA or some future program—will continue to be hamstrung, threatening both the political leaders who support reform, and the quality and sustainability of American health care well into the future.