The Trillion Dollar Revolution: How the Affordable Care Act Transformed Politics, Law, and Health Care in America

Abstract

In the midst of an historic election, with the Supreme Court considering another existential challenge to the Affordable Care Act (ACA) and with the nation plunged into a public health and economic crisis from the 2020 coronavirus pandemic, the ACA is as important as ever. The ACA matters. It matters to many millions who count on its protections to access health coverage, particularly as they lose their job-based insurance in the pandemic. It matters to voters and to their representatives tasked with the next generation of health reform. It matters to states, the health care industry, and businesses who have sunk innumerable resources and time into making the ACA work. The Trillion Dollar Revolution assesses the ACA at 10 years, marking its achievements, trade-offs, shortfalls, impacts, and lessons for future reforms. The ACA was both monumental and paradoxical. It was the single biggest social welfare legislation enacted in 50 years and touched every aspect of our sprawling health care system. Yet the narrow political window for its passage meant that the ACA was incremental, building on, rather than fundamentally restructuring, our fragmented health care system. The ACA was imperfect because it inherited many flaws of the existing health care system. Nevertheless, the ACA achieved something quite revolutionary—it changed the minds of the American public, who have since embraced notions of health care access as a right and preexisting condition protections as a given. Edited by Ezekiel Emanuel and Abbe Gluck, the book reads like an insider’s account and assessment of the ACA. The contributors are a veritable Who’s Who of lawyers, health law scholars, health economists, health policy experts, and political leaders with a front-row view of the ACA. Divided into five parts, the essays discuss the ACA’s (I) policy goals, (II) implementation, (III) legal challenges, (IV) impacts, and (V) lessons for the future. The book is well suited for health law and policy students in college or graduatelevel courses, as well as for academics, journalists, health policymakers, and wonks. Fittingly, the book opens with a chapter by Timothy Stoltzfus Jost and John McDonough, perhaps the two most knowledgeable individuals in the country about the law and policy of the ACA. This chapter could stand by itself for its concise history of the ACA, what drove it, what it did, what worked, and what it did not do. Historians and policy scholars will appreciate the first-person accounts of the difficult trade-offs in passage and challenges of implementation by those who were in the room where it happened, including Kathleen Sebelius, who was the Secretary of Health & Human Services for the passage and implementation; Nancy-Ann DePearle, senior health policy advisor to President Obama; Peter Orszag, the director of the Office of