Episode 8 of The 80 Million Podcast: Beyond Coverage — What It Will Take to Fix American Health Care
We ask what the ACA achieved, what remains unfinished, and how to make coverage durable and affordable.
In this episode of The 80 Million podcast, Chiquita Brooks-LaSure, former Administrator of the Centers for Medicare & Medicaid Services, talks with Patti Boozang, host of The 80 Million Podcast, about what the Affordable Care Act made possible, what remains unfinished, and what it will take to build coverage that is not only expanded, but durable, usable and affordable.
Authors: Patti Boozang
Editor: Amanda Eisenberg
tl;dr
The Affordable Care Act (ACA) fundamentally changed American health care — eliminating discrimination based on pre-existing conditions, dramatically reducing the uninsured rate and cementing the principle that health care is a basic human right. These gains are real and should not be taken for granted.
But coverage alone was never the finish line. Today’s crisis is one of affordability and usability: People with insurance still face crushing costs, relentless prior authorization red tape and a system that burns out the providers they depend on.
The path forward requires mutual sacrifice across all parts of the health care ecosystem, from payers and providers to employers and the government. States can and should still be laboratories for innovation, with the federal government as the setter of a strong national floor.
Reducing friction across the entire health care system may be the single most important structural reform available to us right now.
The 80 Million Impact
This is the final episode of Season 1 of The 80 Million Podcast, a season devoted to Medicaid at an inflection point. But Medicaid doesn’t exist in a vacuum. The pressures bearing down on state Medicaid programs are inseparable from a bigger national reality: coverage is getting harder to get, keep, use and afford — and outcomes in our health care system still don’t match those of our peer nations. So, we widened the lens to talk about the broader health care system – and where we stand today on coverage, access and affordability.
It’s worth remembering that, prior to the implementation of the Affordable Care Act in 2010, patients could be charged more than seven times as much for coverage because of their health conditions. Parts of the body were deemed uninsurable, and women were charged more than men simply because of their gender. States had high-risk pools to help higher risk people that the private market wouldn’t touch. Sixteen years later, most Americans take it for granted that insurers cannot discriminate based on pre-existing conditions — a shift from accepted industry practice to political third rail that represents one of the most durable achievements in modern health policy.
The ACA also moved the needle on something harder to quantify: More Americans today would say that health care is a basic human right than would have said so when the ACA debate began. And the program-level results were real. During the Biden administration, the United States reached its lowest uninsured rate on record. Medicaid expansion brought coverage to people who had waited a decade for the opportunity to enroll.
But coverage was always a necessary condition, not a sufficient one. The political reality at the time the ACA was being crafted and debated was brutal: It was nearly impossible to have a serious conversation about cost and affordability while millions of people remained uninsured, and that urgency crowded out equally important conversations about the structural drivers of cost. The ACA included cost-containment provisions, but many were repealed or never took effect. Now, employer-sponsored coverage is under its own strain. More people with job-based coverage are feeling the financial pinch, along with the maddening bureaucracy of prior authorizations, step-therapy requirements and mid-year formulary changes. The defining question of this era is no longer just “Do you have insurance?” It’s “Does your insurance actually work?”
The current moment makes this worse, not better. Work reporting requirements, more frequent eligibility redeterminations, and tightened Marketplace enrollment rules are often framed as efforts to root out fraud and ensure program integrity — goals no one disputes. But there is a fundamental difference between going after fraud and making everyone prove their worthiness on a more burdensome schedule. When you impose cumbersome paperwork on people working multiple jobs or managing health conditions, you lose people who are absolutely eligible — not because they don’t qualify, but because the process overwhelms them. Physicians are already spending extraordinary amounts of time on administrative work, with some oncologists reporting that paperwork consumes half their working hours. Every hour a provider spends on prior authorization is an hour not spent with a patient.
What comes next — and who has to be part of it
The path forward has to work across all payers. The through lines of dysfunction — misaligned incentives, fragmented data and fee-for-service structures that reward volume over value — run through Medicare, Medicaid, the Marketplace and employer-sponsored coverage alike. Each program has its own logic and constituency, and that diversity isn’t going away. But there are more synergies across the three Ms — Medicare, Medicaid Marketplace — than siloed policy debates suggest. When Medicare cares about something, the rest of the market tends to follow. Most fundamentally, the federal government is the only entity that can set and enforce a national floor, which has eroded through court cases, Congressional action and administrative decisions.
Health care is a fifth of the American economy. It must be rebuilt and defended. Remaking it requires mutual sacrifice, a long view and enough stakeholders who can see themselves in a better future. We have a lot of work to do. But the path exists.
The Bottom Line
Listen to the full conversation on Spotify, Apple Podcasts , or wherever you get your podcasts to understand what the ACA made possible, what this moment puts at risk and what structural change could actually move the needle on coverage that is durable, usable, and affordable.
And don’t forget to subscribe to The 80 Million Podcast.