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Moreover, the highly salient and partisan nature of Medicaid expansion has made it difficult for interest-group coalitions and progressive administrators to play a leading role in policy change. The future of Medicaid expansion, as well as other significant portions of the ACA, will continue to depend on the character of representative democracy in the states.A growing body of literature examining the effects of the Affordable Care Act (ACA) on nonelderly adults provides promising evidence of improvements in health outcomes through insurance expansions. Our review of forty-three studies that employed a quasi-experimental research design found encouraging evidence of improvements in health status, chronic disease, maternal and neonatal health, and mortality, with some findings corroborated by multiple studies. Some studies further suggested that the beneficial effects have grown over time and thus may continue to grow if the ACA insurance expansions remain in force. However, not all studies reported a significant positive relationship between ACA provisions that expanded insurance coverage and health status. click here We highlight the challenges facing researchers, including the importance of nonmedical factors in determining individual health and the use of outcome data predominantly drawn from self-reports. In closing, we identify opportunities to enhance researchers' understanding of the relationship between the ACA insurance expansions and health outcomes using new data sources, including electronic health records.Enrollment in the Marketplaces of the Affordable Care Act (ACA) has fallen short of original expectations, because the ACA's regulatory changes made coverage costlier for many Americans with incomes above 150 percent of the federal poverty level. There are ways to strengthen and expand the role of the individual market in providing affordable, personalized options to all nonelderly Americans. These include insured people in costly group plans, uninsured people in good health but without affordable options, those with preexisting conditions, and those who live in states that did not expand eligibility for Medicaid. A more robust individual market could expand coverage so that it would be more sustainable than the status quo. Much as the authors of the Affordable Care Act drew on Massachusetts reforms signed into law by Gov. Mitt Romney (R), market-oriented health reformers should learn from the ACA and Medicare's private insurance programs in order to build a personalized, consumer-driven path toward universal coverage.The Affordable Care Act (ACA) led to the largest expansion of health insurance in the US in fifty years, bringing the uninsurance rate to its lowest recorded level in 2016. But even at that point, nearly thirty million people lacked health insurance, and millions more still struggled to afford needed medical care. Recent studies also indicate a partial erosion of the ACA's coverage gains since 2017. This article identifies the underlying causes of these problems and evaluates potential policy remedies. Topics include the slow but steady growth of state expansions of eligibility for Medicaid; new waiver approaches in Medicaid, including work requirements; high cost sharing and premium growth in both the Marketplaces and employer coverage; and proposed systemic overhauls such as Medicare for All.The media has long wrestled with how to communicate the complex policies and politics that drove the implementation of the Affordable Care Act.The ACA has increased access to health care for vulnerable populations; decreased the percentage of Americans who say they went without care due to cost; and spurred America's insurers, hospitals, and clinicians to change how they deliver and pay for health care. At the same time, the ACA has been challenged in the courts of justice and public opinion.Large disparities in health insurance coverage and access to health services have long persisted in the US health care system. We considered how the insurance coverage expansions of the Affordable Care Act have affected disparities related to race and ethnicity. In the years since the law went into effect, insurance coverage has increased significantly for all racial/ethnic groups. Because coverage increased more for non-Hispanic blacks and Hispanics than for non-Hispanic whites, disparities in coverage have decreased. Despite these improvements, a large number of adults remain uninsured, and the uninsurance rate among blacks and Hispanics is substantially higher than the rate among whites.Providing high-quality primary care is key to improving health care in the United States. The Affordable Care Act sharpened the emerging focus on primary care as a critical lever to use in improving health care delivery, lowering costs, and improving the quality of care. We describe primary care delivery system reform models that were developed and tested over the past decade by the Center for Medicare and Medicaid Innovation-which was created by the Affordable Care Act-and reflect on key lessons and remaining challenges. Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality.The Affordable Care Act promoted payment reforms directly and through the creation of the Center for Medicare and Medicaid Innovation, which it endowed with the authority to introduce Alternative Payment Models (APMs) into Medicare and Medicaid. We conducted a narrative review of these payment reforms, finding that several programs generated modest savings while maintaining or improving the quality of care, but they had high dropout rates. In general, evidence for other APMs is less conclusive, and whether the reforms spurred similar changes in the private sector remains anecdotal. Despite challenges, APMs provide incentives for efficient care provision and offer providers a way to succeed financially in an environment with slowly rising fee-for-service prices. Thus, we consider the Affordable Care Act's payment reforms to be modestly successful, and we encourage both the purging of initiatives that aren't working and the continued development and study of promising ones.