The Affordable Care Act (ACA) made what many people thought would be lasting changes to U.S. health care when it was passed in 2010. Most people by now take for granted the health care reform package, fully implemented by 2014. It’s likely that many Americans have forgotten how bad things were before the ACA, when more than 50 million people—16 percent of the population—went without health insurance.
But “Obamacare,” as the reform package was once derisively known, did not, in the end, move all Americans under its insurance umbrella: In 2010, Democrats seeking a compromise withdrew a public option in order to get something over the line. That means the ACA remains only a step on the path to universal coverage, which has been commonplace among other advanced economies of the world for decades.
The ACA has had some successes. It lowered health care costs overall and prevented 129 million people with previously existing conditions, some life-threatening, from being unable to receive care. It expanded family coverage to include children up to the age of 26, closing a coverage gap that had often swallowed young people just out of college. “Optional” health care such as mental health services, maternity care, and prescription drugs became mandatory, and lifetime limits on health care expenses were outlawed.
Despite that progress, more than 26 million people remain uninsured, and a recent report from the Commonwealth Fund offers more evidence that health services in the United States lag significantly behind the care delivered among peer states. The United States scored last among 10 Western nations compared in the analysis, beaten out by Australia at number 1 (followed by the Netherlands and the United Kingdom). The report’s summary was especially disheartening: “The U.S. continues to be in a class by itself in the underperformance of its health care sector.”
U.S. health care is the world’s most expensive but produces the worst outcomes in the affluent world. Americans are not getting their money’s worth out of the nation’s substantial outlay—$4.5 trillion in 2022, 17 percent of the gross national product. According to the Commonwealth Fund, the United States ranked ninth in equity and ninth in “administrative efficiency.” Anyone who has been on the phone with their insurer knows exactly what that means.
The Commonwealth Fund offered some semiobvious recommendations to improve health care in the United States: expand insurance coverage, shrink disparities in care, and reduce the administrative burden and complexities of insurance plans. They sound like reasonable steps toward a complete revolution; for example, turning to a single payer system or national health program like that offered in nations that scored higher than the United States in the Commonwealth Fund analysis.
“It seems more probable that the United States is beginning a period when the true fight will be preventing the gains of the ACA from slipping away.”
Unfortunately, after the results in the 2024 presidential contest, neither incremental nor revolutionary change seems likely. In fact, it seems more probable that the United States is beginning a period when the true fight will be preventing the gains of the ACA from slipping away.
During his campaign, President-elect Donald Trump targeted the ACA, promising to pull the plug on it should he become president. He made much the same promise during his first campaign in 2015, meaning he has had nine years to outline a program that will improve on or replace the ACA; but it seems he has only come up with a “concept of a plan” during his interregnum.
As Trump returns to Washington, 45 million Americans rely on the ACA for their health care. That is all in jeopardy. The ACA will celebrate its 15th anniversary in March, assuming it survives the first months of the Trump restoration.
This article also appears in the January 2025 issue of U.S. Catholic (Vol. 90, No. 1, page 42). Click here to subscribe to the magazine.
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