The US health care system has undergone remarkable transformation over the past century. Policy proposals to create a national health insurance system date back decades and have faced multiple political headwinds but focused on similar and consistent themes: achieving universal health care coverage, containing high and rising health care costs, and increasing competition among private plans.
When President Obama came to office in 2008, his administration faced compounding health system challenges. Nearly 45 million Americans lacked health insurance coverage. Concerns that private plans were overtly prioritizing profits rather than patients had intensified. National health care costs had risen to 17% of the gross domestic product. At the same time, health outcomes in the United States were worse than comparable countries. In 2010, President Obama signed the Affordable Care Act (ACA) into law, which had 3 areas of focus: expanding coverage through public and private payers, reforming health insurance markets to be more patient-friendly, and improving quality of care and reducing spending through value-based payment programs.
The ACA addressed high noninsurance rates in the United States with an individual mandate, which required most people to obtain health insurance, and by creating government-run public marketplaces (exchanges) where individuals could obtain insurance plans, often subsidized for lower income buyers. At the same time, the ACA also expanded Medicaid coverage to all adults with incomes up to 138% of the federal poverty level. Though this was intended to be a national expansion, a later Supreme Court challenge established it as optional; consequently, 25 states (including DC) expanded Medicaid in 2014, and an additional 16 subsequently elected to do so, leaving 10 states without expansion as of January 2024. As a result of these efforts, roughly 20 million adults gained health insurance coverage.
Medicaid expansion has improved access to primary and preventive care, increased the diagnosis and treatment of cardiometabolic risk factors, and reduced catastrophic health expenditures while also narrowing racial inequities in coverage and access.1 At the same time, states that expanded Medicaid experienced declines in uninsured cardiovascular hospitalizations and increases in access to advanced cardiovascular therapies. Perhaps most importantly, Medicaid expansion has likely improved health—one study estimated the first 4 years of expansion saved nearly 20 000 lives, driven by reductions in cardiovascular deaths.2
Another key step forward under the ACA was the requirement that private plans provide certain preventive services with zero out-of-pocket costs. This policy change had important effects on the use of preventive services for cardiometabolic conditions. The ACA also prohibited health plans from denying coverage to patients with preexisting conditions, increasing
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