The U.S. Supreme Court today ruled 6-3 in favor of letting the Patient Protection and Affordable Care Act (PPACA) public exchanges operated by the U.S. Department of Health and Human Services (HHS) continue to offer PPACA premium subsidy tax credits.

The petitioners in the case, King v. Burwell (Case Number 14-114), argued that PPACA clearly gives state-established exchanges the authority to offer the tax credits but does not say whether HHS-established exchanges can do so.

HHS Secretary Sylvia Burwell and other Obama administration officials have argued that the intent of PPACA as a whole is obviously to expand access to health coverage through the premium tax credit system, and that keeping the HHS-established exchanges from offering the tax credit would conflict with that goal, by shutting lower-income consumers out of the market and saddling the insurers still in the market with a sicker pool of enrollees who would be much more expensive to cover. 

See also: Public exchanges have 10.2 million paid enrollees

Chief Justice John Roberts writes in an opinion for the majority that the petitioners are correct that the language of the PPACA HHS exchange tax credit provision is ambiguous.

But, here, given the intent of the PPACA premium tax credit program as a whole, “the statutory scheme compels us to reject petitioners’ interpretation because it would destabilize the individual insurance market in any state with a federal exchange, and likely create the very ‘death spirals’ that Congress designed the act to avoid,” Roberts writes.

See also: Vendor offers insurers a King v. Burwell rescue service

Roberts cites an earlier ruling in which the court held that the court cannot interpret federal statutes to negate their own stated purposes.

Roberts also cites a study suggesting that eliminating the tax credit in the HHS exchanges could increase premiums by 47 percent and cut enrollment by 70 percent, and another study suggesting that eliminating the tax credit could increase premiums by 35 percent and cut enrollment by 69 percent.

“It is implausible that Congress meant the act to operate in this manner,” Roberts writes.

Justices Antonin Scalia, Clarence Thomas and Samuel Alito dissented.

Scalia writes that the majority’s interpretation of the PPACA premium tax credit language is “of course quite absurd.”

“Under all the usual rules of interpretation … the government should lose this case,” Scalia writes. “But normal rules of interpretation seem always to yield to the overriding principle of the present court: The Affordable Care Act must be saved.”

The King v. Burwell ruling came out almost exactly three years after the court’s ruling on NFIB v. Sebelius, in which the court upheld the authority of Congress to use a tax penalty to encourage consumers to buy commercial health insurance coverage.

The Obama administration had refused to discuss contingency plans for keeping a ruling against HHS from disrupting the commercial individual health insurance market.

Republicans came up with a series of proposals of their own, but some observers questioned whether Republican leaders could have persuaded Republican lawmakers who would be willing to extend the subsidies and Republican lawmakers who strongly oppose an extension to agree on any relief measures that President Obama would sign into law.

The next big life-or-death challenge PPACA advocates and administrators will face will be seeing how the big three PPACA health insurance company buffer programs work as they begin paying benefits to insurers.

One of the programs, a temporary reinsurance program, is supposed to tell eligible health insurers Tuesday how much cash they may get to defray the costs of enrollees who filed catastrophic claims in 2014.

Health insurers are supposed to use that information to file a reporting form for another PPACA risk-management program, a risk corridors program, which is supposed to use cash from health insurers that did well in 2014 to help health insurers that had poor underwriting results that year.

See also: 

PPACA Decision: The PDF, with Interesting Parts Highlighted

Feds: “We’ll send some PPACA lifeboat money in December”

Republicans face conservative pressure on PPACA subsidies

Analyst: ‘Good PPACA reinsurance news’ is not so good

5 Oregon insurers under orders to raise their rates