The Problem

Nearly a decade since the contentious passage of the 2010 Patient Protection and Affordable Care Act (ACA), which aimed to expand Americans’ access to health insurance, the legislation remains highly controversial. Several attempts to repeal and replace the law failed in 2017, but legislative and executive action have altered the law in fundamental ways since then. Public opinion on the ACA has remained divided since its passage, with about 40 percent of the U.S. public reporting an unfavorable view both immediately after its passage in 2010 and in mid-2019. Instead of the ACA ushering in reform and subsequent stability for the health care system, it does not function the way it was originally intended and Americans have not coalesced around it. This has set the stage for a continued battle for health care reform.

Notably, the ACA did not fundamentally reshape the U.S. health care system. Prior to the ACA, the U.S. was the only developed nation without universal health care, and it retains that distinction even postreform. Americans receive health insurance through a labyrinthic and patchwork-like system, in which one's age, economic situation, and employment status dictate coverage. About half of Americans receive insurance through an employer (whether their own or a partner’s/parent's employer), coverage which is generally terminated upon retirement or changing jobs. After turning 65, the vast majority of older Americans are shuttled into a different health insurance system, receiving their coverage through the federal Medicare program. About a quarter of Americans receive coverage through the Medicaid program, a public health insurance program for people with low income that is funded jointly by the state and federal government. Although the ACA attempted to extend Medicaid coverage to all Americans with income up to 138 percent of the federal poverty line, 14 states have not expanded their Medicaid coverage as of July 2019. Therefore, inconsistencies in eligibility for Medicaid persist across states, with some states imposing work requirements on recipients, limiting eligibility to certain groups, and/or drawing eligibility thresholds even lower than the federal poverty line.