Abstract

Excerpted From: Wendy E. Parmet and Jasmine M. Howard, Beyond Health Reform: The ACA and the Social Drivers of Health, 50 Seton Hall Journal of Legislation & Public Policy 62 (2026) (115 Footnotes) (Full Document)

On this fifteenth anniversary of the Affordable Care Act (ACA), when its very future is in doubt, it is worth assessing one of the Act's greatest paradoxes and limitations: although the ACA significantly reduced the rates of uninsurance, thereby expanding access to care by many measures, the U.S. population continues to experience poorer health than peer countries. This essay reflects on some of the reasons for this failure.

Prior to the ACA's passage in 2010, one important reason for the discrepancy between health outcomes in the U.S. and those in peer nations was that as many as 46. million Americans were uninsured,4often because they lacked access to employer-provided coverage and could not afford (sometimes due to pre-existing conditions) individual coverage. The uncompensated costs of uninsured Americans taxed both the health care system and individuals. One life-saving procedure could leave a family struggling to pay medical bills for years, if not bankrupt them. It could also cause their insurance to be cancelled, increasing their vulnerability if they required additional care. But even those with robust coverage suffered as emergency rooms filled with uninsured individuals seeking care for non-emergency medical conditions.

Although far from perfect, the ACA went a long way towards ameliorating these problems. Following its passage, the number of uninsured Americans rapidly fell. By 2016, the rate of uninsurance among the non-elderly population dropped to historic lows of 10 percent, or about 26. million; the Act also expanded access to care for the poorest Americans through the Medicaid expansion. In 2024, even fewer Americans were uninsured. Moreover, with expanded protections for people with pre-existing conditions, the ACA helped make access to insurance more stable. People no longer had to fear that they were one diagnosis away from losing their health coverage.

Despite these successes, the cost of health care continued to increase, and poor health outcomes and morbidities have remained the same or worsened. The U.S. greatly surpasses its peers in health care spending as a percentage of GDP, yet its life expectancy ranks forty-ninth, a decrease in the U.S.' overall world ranking since 2016. More troubling, as of 2024, the United States ranked 173rd for infant mortality with 5. deaths per 1, live births. The incidence rate of diseases, such as colon cancer, diabetes, and heart disease, are not only rising, but they are also becoming more prevalent in younger populations. Such sorry statistics and trends suggest that the expansion of insurance alone has not done enough to improve the population's health as many of the law's advocates hoped. The reason for this failure, we argue, is that the ACA focused on creating significant improvements in access to and affordability of health insurance: it did not and perhaps could not address the root causes of poor population health.

In the essay that follows, we explain why the ACA has failed to improve population health in the U.S. In Section I, we introduce the concept of the social determinants (or drivers) of health ("SDOH") and explain how they impact both population and individual health. We also note how interventions that aim to improve health can operate at different levels. In Section II, we look at the impact of several different provisions within the ACA that aim to improve not only access to health care but also population health. We also explain why these provisions have proven to be less effective in redressing the SDOH than their advocates might have hoped. In the Conclusion, we offer some thoughts on the relationship between health care reform and population health and argue that while expanding access to health care is an important policy imperative, it cannot and should not be thought of as a primary tool for improving the population's health. This is a lesson that policymakers need to take to heart, if and when they return to the goal of improving access to health care and improving population health.

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The ACA marked a significant, if imperfect, attempt to reform the health care system. Through its provisions increasing access to insurance, mandating cost-free preventive services, and nudging payors and providers to pay increased attention and support to social services, the ACA has also touched upon the SDOH. But as a health care reform law, the ACA was never designed to, and could not, mark major improvements to the SDOH. As a result, its impact on Americans' health, as opposed to their health care, was always bound to be marginal.

In saying this, we do not mean to suggest that the ACA was a failure, nor that its goal of expanding access to health insurance was illconceived. It is quite the opposite. Access to health care, which usually requires robust insurance, is often critical to maintaining individual health and can be an important building block of population health. Or, to put it another way, the ACA's efforts to expand and protect coverage were a necessary but insufficient effort to improve population health.

Unfortunately, even that effort is now threatened. In July 2025, Congress passed and President Trump signed the "One Big Beautiful Bill" that imposed deep cuts on Medicaid. Republicans have also refused to extend enhanced subsidies for purchasing insurance on the ACA that were enacted during the Biden Administration, a decision that, should it hold, will significantly raise the cost for many who purchase insurance on the exchanges. In addition, the Trump Administration has issued a proposed rule that will make enrollment in the ACA's marketplace more challenging. Such policies and others that the new Administration have instituted or will develop in the coming years may unwind some of the increases in health insurance rates that resulted from the ACA. and other changes proposed or implemented by the Trump Administration, including steep cuts to state and local health departments, may further weaken the nation's already underfunded public health system.

More spending cuts that may be coming, including decreased food assistance, removing college loan assistance, and changes at HHS, NIH, and CDC, may have additional profound impacts on the drivers of health for Americans, likely for decades to come. As explained throughout this paper, the SDOH are implicated in policies, legislation, and the law, including the decisions of judges, which may be pivotal to determining the outcome of proposed regulatory changes. Social mobility, increased opportunities for education, clean air and water, public transit infrastructure, amongst countless others, all have implications for a healthy society. Cutbacks in these areas, especially if implemented without care and nuance, may further imperil the nation's health.

If we truly want to "Make America Healthy Again," as Department of Health and Human Services Secretary Robert F. Kennedy Jr. has declared, we need to look beyond the health care system and health reform. The job of addressing population health belongs first and foremost to our lawmakers and health officials, at all levels. Whether they currently have the interest in or authority to undertake meaningful measures to improve the SDOH remains to be seen. Despite the bleakness of the moment and the multiple threats to health care access, public health programs, and other measures designed to remedy adverse SDOH, for this celebration of the ACA, we choose optimism.

Wendy E. Parmet, Matthews University Distinguished Professor of Law, Northeastern University. 

Jasmine M. Howard, Adjunct Professor of Law & Program Director, Salus Populi, Northeastern University.