Health care for all: Dream, nightmare or one big muddle?
The Affordable Care Act turns 16 this year, and Medicaid covers nearly 70 million low-income Americans. The Trump administration and the Republican Congress Enhanced premiums were allowed to lapse, and new regulations allow less comprehensive insurance plans. Next January, many people covered under the Medicaid expansion will face work or community engagement requirements — and some may lose coverage.
So where is health policy headed?
That was the main question debated at the opening plenary at Health Journalism 2026 in Minneapolis by two prominent policy veterans: Jeanne Lambrew, who helped draft and implement the Affordable Care Act and is now director of health care reform and senior fellow at The Century Foundation; and Chris Pope, an ACA critic who is a senior fellow at the Manhattan Institute and a former GOP staffer for the House Energy and Commerce Committee. Jonathan Cohn, senior national correspondent at The Bulwark, moderated.
What’s the government’s role in health care?
Cohn opened with a broad question: Should the U.S. government guarantee health care for every resident?
Lambrew thinks so, and pointed to data that suggests the public agrees. A recent survey from Pew Research found that 66% of Americans believe the federal government has a responsibility to ensure coverage for all. Nearly one-third of all federal spending, or about $2.4 trillion, will be spent on health care this year, according to Lambrew. For context, the amount spent on Social Security is $1.4 trillion, and on defense, 1.8 trillion. Frustration with the private health sector has reached a tipping point, Lambrew said.
“Even though in the past people have been skeptical of government,” Lambrew said, “they may be, at this point in time, even more frustrated with the private sector.”
Pope pushed back, saying that debates about “universality” tend to obscure hard questions about how much coverage, for what services, and at what cost.
“We have a very frequent, two-track discussion of health care,” he said. “We have a discussion in the public, which is often ‘Should people have a right to health care or not?’ And then we have a discussion among experts, which is, ‘How much, and who pays for it?’”
An open-ended commitment to cover anything where the marginal benefit is greater than zero, regardless of what the marginal cost may be, is both fiscally unsustainable and a root cause of the American health cost spiral, according to Pope. “That’s the essence of so much of good health policy making,” he said. “It’s the, ‘To what extent?’ question.”
The ACA: Wins, losses, and undecided
Both speakers broadly agreed that the ACA achieved its main goals of expanding coverage and, at least in its first decade, slowing the growth of health care spending as a share of the economy. The share of Americans with health coverage reached 92% in 2024, according to the National Center for Health Statistics, Lambrew noted. This is close to Canada’s rate once undocumented immigrants and other excluded U.S. populations are accounted for.
But their views on how well this coverage, and the health care system as a whole works, differ sharply.
Pope focused on the Medicaid expansion, which he called the law’s largest and most structurally flawed component. Two problems stand out to him. First is the 9-to-1 federal to state matching rate, which created misaligned incentives for states to reclassify spending in order to maximize federal dollars. Second is evidence that a significant share of the people covered under the expansion previously had private insurance, even though expansion was designed to reach the uninsured.
“I think the majority of the Medicaid expansion has actually just gone to supplement, replace, eliminate, or displace a part of insurance coverage that existed, rather than precisely filling in the gap that existed,” Pope said.
Lambrew strongly disagreed. If private insurance had been crowded out, she said, the number of people with employer or other coverage would have declined significantly after the expansion, and it didn’t. “It was not privately insured people,” she said. “It was only people that otherwise wouldn’t be insured at all.”
Perhaps surprisingly, Pope does not support the work requirement, which goes into effect in January 2027 and has broad Republican support. But Pope thinks the current requirements are too easy for states to satisfy, providing little real accountability. Instead, he favors time limits on Medicaid coverage for working-age, non-disabled adults, giving them a defined window to find other insurance while they’re in the workforce.
What could actually get done next?
Asked what a realistic near-term reform agenda might look like, both speakers identified areas of potential movement and, to some degree, overlapping priorities.
Lambrew highlighted extending enhanced premium tax credits for marketplace coverage as a likely bipartisan priority, particularly for the self-employed, the semi-retired and those without access to employer-sponsored insurance.
She flagged prior authorization reform such as requiring faster decisions, standardized appeals, and transparency as an area with cross-aisle appeal. And, she predicted there will be political pressure to walk some of the new Medicaid policies back as the consequences, including people losing coverage, become apparent.
Pope’s recommendation targeted employer-sponsored insurance, which he called an underappreciated driver of hospital price inflation. Because employer plans must cover workers spread across an entire metro area, they’re forced to contract with virtually every hospital system. This gives providers enormous pricing leverage. Individual market plans negotiate more aggressively, he said. He said expanding Health Reimbursement Accounts, which allow employers to direct pre-tax funds for workers to buy individual-market coverage.
“Individuals can be much more aggressive about finding the plan that works for them,” he said. “And those incentives can go all the way down,” eventually influencing hospitals’ spending.
Policy changes are likely
“No single law has a shelf life of 16 years,” Lambrew said of the ACA. “Funding has changed, loopholes have arisen. We couldn’t anticipate what came next.”
Pope agreed the ACA had addressed real problems but in ways that were too open-ended and lacking cost discipline.
What both experts did agree on is that choices being made in Washington and in state legislatures now about Medicaid eligibility, marketplace subsidies and federal matching rates will shape who can access health care in this country for a generation.
