From the Editors

10 years into the Affordable Care Act, a pandemic exposes its limits

The ACA never attempted the kind of structural reform our health-care system needs.

The Affordable Care Act celebrated its tenth birthday last month, just as the US health-care system faces an unprecedented stress test. Shortages of COVID-19 tests, protective gear for health-care workers, hospital beds, and ventilators have exposed weaknesses in our health-care system—and sown confusion and fear.

For decades significant change in the US health-care system has been difficult to come by, in part because of a widespread belief that the system ranks among the best in the world. Critics have long countered that, while excellent care is indeed available in the US, it isn’t available to enough people. Now the reality of that disparity is being played out in frantic hospitals throughout the country. Right now, the US’s trajectory for the spread of the new coronavirus is worse than any other country’s, and life-and-death decisions are being made—based not on the expertise of doctors but on the availability of life-saving equipment. We know how to save lives, but we don’t have adequate resources.

The ACA, which was enacted with a razor-thin margin of political support, did a lot to extend health insurance to more people. But it also assented to the argument that deeper structural change was not needed. It preserved the system’s essential qualities as a private, decentralized, profit-seeking industry. It left in place high deductibles so that many of the newly insured would pay for their health care out of pocket anyway. After it passed, health-care costs continued to go up—while the number of hospital beds continued to go down. There are fewer hospital beds per capita in the US than in China or Italy, and one-quarter the number in South Korea.

Add to that the economic impact of the virus. In a single week last month, 3 million workers filed for unemployment insurance. This means that in the midst of a pandemic, millions of people are scrambling to secure health insurance because they have lost their employer-sponsored plans. Because of the ACA, they can turn to the insurance exchanges, apply for the necessary subsidies, and perhaps find a workable plan. That’s if they can navigate the process, under stress and on the fly—and if they can afford the deductibles.

All of this calls out for a more thorough rethinking of our health-care system than the ACA attempted. The assumption that health care is rightly decentralized and for-profit has perpetuated problems of access—along with a business incentive to minimize empty hospital beds and idle equipment, the very things needed to save lives in a crisis like this one. It has helped lead us to where we are at this moment.

Perhaps when the dust settles, we will be willing to take a hard look at the failures of our system. Perhaps we will at last be ready to reconsider its very structures, in order to create a system that works better for all.

A version of this article appears in the print edition under the title “A decade of small reforms.”