Document Type
Working Paper
Publication Date
12-2025
Language
en-US
Abstract
As part of the symposium "15th Anniversary of the ACA: A Health Equity Review," this essay explores the ACA's mix of private law and public law provisions that rendered measurable improvements in health equity and health outcomes, especially for populations that experienced longstanding health disparities before its enactment. Congress’s central objective was near-universal health insurance coverage, and the ACA employed a variety of mechanisms to reach that goal. The law’s health equity successes grew from establishing a principle of inclusion across federal statutes. This principle, which I have called “universality,” centered a human right to health approach: No longer would federal law permit exclusion of people who could not pay, or were otherwise deemed undesirable or unworthy of assistance, from health insurance coverage or health care. The principle of universality was fundamentally a health equity policy that brought the U.S. in line with other wealthy nations; yet, it also has been a source of conflict, driving political fighting over the ACA since the law’s enactment in 2010 and slowing its implementation.
Whereas anyone who needed medical care before 2010 had to be able to pay or could be turned away, the ACA made it so people became eligible for coverage as well as insurable through placing limits on actuarial practices that restricted coverage, eligibility, and benefits. For political expediency, Congress built on the fragmented U.S. non-system of health care, using the federalism-based governance structures already in place. The ACA relied heavily on Medicaid, the public health insurance program for low-income individuals, to anchor universal health insurance coverage and operationalize access to care for people who had no other paths to coverage. The law’s reliance on federal/state partnerships became central to negotiating ACA implementation during the Obama administration, however, federalism also created ongoing barriers to implementation by allowing states to opt out of Medicaid expansion, resist health insurance exchange establishment, and reject other policy partnerships. This made federalism both a strength and a weakness, paradoxically a feature of the ACA that has both served and undermined health equity.
In other words, the ACA’s animating universality principle was powerful, but it did not end the political fights over who gets assistance or which level of government is responsible for that help. To explore these tensions, Part II provides context, very briefly explaining historical norms of health care exclusion in the U.S. Part III examines the ACA’s greatest health equity tool—Medicaid expansion—and describes three phases of implementation that roughly have corresponded to policy variation, but also historical events, from one presidential administration to the next. States’ differing paths to ACA implementation illuminate the political fights against the universal coverage goal but also democratic successes along the way. In Part IV, the essay considers whether the ACA has become a durable statutory foundation for improving health equity, drawing lessons from Medicaid expansion and the health insurance exchanges to tell a broader story about ACA-based coverage leading to improved health in expansion states and ongoing problems (i.e. rural hospital closures) for non-expansion states. Finally, the essay considers new and ongoing challenges, such as the policies in the 2025 H.R.1 Medicaid cuts. Congress employed tools like work reporting requirements to enervate the ACA’s universality by reintroducing concepts of deservingness and creating barriers that will produce sharp decreases in insurance coverage.
Recommended Citation
Nicole Huberfeld,
The Power and Peril of the ACA's Universality at Fifteen
(2025).
Available at:
https://scholarship.law.bu.edu/faculty_scholarship/4182
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