Building on the ACA to Achieve Universal Coverage

NEJM March 27, 2019
Matthew Fiedler, Ph.D., Henry J. Aaron, Ph.D., Loren Adler, B.A., Paul B. Ginsburg, Ph.D., and Christen L. Young, J.D.

For decades leading up to enactment of the Affordable Care Act (ACA), the United States failed to reduce the percentage of Americans who lacked health insurance coverage. Since the ACA’s passage, the percentage of U.S. residents without coverage has fallen by almost half, from 16% to approximately 9%. Yet more needs to be done if we are to achieve universal coverage.

The bar graph, which draws on estimates by researchers at the Urban Institute, shows which groups remained uninsured in 2017.¹ In our view, these estimates make clear that achieving universal coverage within the framework created by the ACA requires four basic steps: implementing the ACA’s Medicaid expansion in all states, increasing and expanding financial assistance to people who purchase...

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