After decades of failed attempts to enact comprehensive health care reform, President Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010. The Affordable Care Act (ACA) has been regarded as the most significant piece of domestic policy legislation since the establishment of Medicare in 1965. The ACA would cover an estimated 32 of the 50 million uninsured Americans by expanding Medicaid, providing subsidies to lower income individuals, establishing health insurance exchanges, and restricting insurance companies from excluding patients from coverage. The ACA also includes many payment and health care delivery system reforms intended to improve quality of care and control health care spending. Soon after passage of the ACA, numerous states and interest groups filed suits challenging its legality. Supreme Court consideration was requested in five cases and the Supreme Court selected one case, brought by 26 states, for review. Oral arguments were heard this spring, March 26-28. The decision will have far reaching consequences for health care in America and the practice of gastroenterology for decades to come. This article reviews the four major issues before the Supreme Court and implications for health care reform and future practice of gastroenterology. Payment reforms, increased accountability, significant pressures for cost control, and new care delivery models will significantly change the future practice of gastroenterology. With these challenges however is a historic opportunity to improve access to care and help realize a more equitable, sustainable, and innovative health care system.