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The Fragility of the Affordable Care Act's Universal Coverage Strategy

This Essay examines the very fragile nature of the Patient Protection and Affordable Care Act’s (ACA) approach to near-universal health insurance coverage, as accentuated by a variety of implementation hurdles and challenges. The ACA’s vision for expanding insurance coverage was to build on our existing patchwork of market-based health insurance delivery for most, combined with government insurance for select segments of the population. But that patchwork strategy is only as strong as the threads that tie it together. Over the past four and a half years since the ACA was enacted, the threads have unraveled in several critical spots. The essay examines the impact and potential impact of judicial, administrative, and other attacks on three key areas of reform: government health care programs, employer-sponsored health insurance, and the individual private market.