The Problem

Numerous sources, including the World Health Organization, Institute of Medicine, and the Commonwealth Fund, show that the U.S. spends more than any other developed nation on health care, but lags behind in terms of key health indicators such as life expectancy and infant mortality. Despite the high spending, U.S. citizens express lower satisfaction with their health care than those in other industrialized nations, and the U.S. is the only developed country that does not have a universal health care system. These shortcomings, coupled with steady growth in the number of uninsured and underinsured Americans, set the stage for the passage of the Patient Protection and Affordable Care Act (hereafter referred to as the ACA) in 2010. Although legislators aimed to solve a major social problem by making health care more accessible and affordable, early results suggest this intent has not been fully realized. The number of uninsured peaked at over 49 million in 2010, according to estimates by the U.S. Census Bureau. By 2015, a Kaiser Family Foundation (KFF) analysis shows this number had dropped to 32 million after passage and implementation of the ACA. Although a reduction in the number of uninsured is laudable, millions of Americans remain uninsured, and health care is still not considered a basic human right.

The ACA aimed to expand insurance coverage to more Americans through three main avenues: increasing employer responsibility, increasing individual responsibility, and increasing government responsibility. It also placed a number of restrictions on insurance companies, such as prohibiting consideration of pre-existing conditions and placing annual or lifetime limits on coverage. These changes have been beneficial in reducing the number of people who are uninsured and helping to ensure that Americans have more comprehensive coverage. However, recent evaluations of the legislation point to some enduring challenges. Estimates by KFF suggest that, of the 32 million people who remain uninsured, about half are either eligible for Medicaid or subsidies to aid them in purchasing insurance. Another 10 percent are individuals who fall into the Medicaid gap: they live in states that did not expand their Medicaid program, but have income too low to qualify for subsidies that would help them purchase insurance. Fifteen percent are undocumented immigrants, who are not eligible for Medicaid or subsidies to purchase insurance through the exchange.