Do the Pros Outweigh the Cons of the Affordable Care Act?
This paper examines whether the benefits of the Affordable Care Act (ACA) outweigh its drawbacks. Drawing on scholarship in health economics, public health policy, and health care delivery, the paper argues that the ACA's ostensible advantages—expanded Medicaid access, elimination of coverage limits, and incentives for preventive care—are undermined by deeper structural problems in the U.S. health care system. Chief among these are the profit-driven nature of the industry, rising insurance premiums and deductibles, the marginalization of smaller providers through Medicare reimbursement cuts, and accelerating market consolidation. The paper ultimately concludes that the ACA's cons outweigh its pros because the legislation fails to address—and in some respects reinforces—the fundamental economic incentives that keep health care unaffordable and patient-care quality declining.
- Introduction: Historical context and thesis against ACA
- Background: The ACA's Intended Goals: ACA's legislative goals and early praise
- Why the Pros Don't Outweigh the Cons: Profit incentives undermine ACA's preventive care goals
- Profit-Driven Care and the Insurance Mandate: Insurance mandate failures and opioid crisis links
- Market Consolidation and the Erosion of Competition: ACA accelerates hospital mergers and monopoly power
- Conclusion: Cons structurally outweigh ACA's intended benefits
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What makes this paper effective
- The paper opens with a historical arc—tracing insurance coverage rates from the 1940s to the ACA era—that grounds the argument in concrete context before advancing the thesis.
- It relies on a range of source types: peer-reviewed journals, long-form journalism, and policy reports, giving the argument breadth across economic, clinical, and political dimensions.
- The paper consistently applies a cost-benefit logic, framing each "pro" of the ACA and then systematically showing how structural factors convert it into a net negative.
Key academic technique demonstrated
The paper demonstrates effective use of the "concede and refute" technique. It acknowledges the ACA's stated goals and the praise it received from scholars like Rosenbaum (2011) before marshaling counterevidence from economists and policy analysts to show that those goals were undermined by market dynamics. This moves the argument beyond simple opposition into a nuanced critique.
Structure breakdown
The paper opens with a historical introduction and thesis statement, followed by a background section on the ACA's legislative intent. The central argument unfolds across two analytical sections—one addressing the incentive structure of profit-driven care and the insurance mandate, and one addressing hospital consolidation and market power—before a conclusion that synthesizes the cons and reasserts the thesis. This structure mirrors a classic persuasive essay: context, context rebuttal, evidence, and synthesis.
Introduction
Before the 1970s, the majority of people held hospital insurance. In the 1940s, for example, only a tenth of the population had private health insurance. Just forty years later, that trend had reversed: a little more than 10% were uninsured, and everyone else had purchased coverage (Morrisey, 2013). This shift resulted from government subsidization of care, which raised the price of care and prompted more people to seek coverage. Employers offered coverage as an incentive to attract workers, but with the increase in premiums and deductibles, more people began viewing even insurance as too expensive and started avoiding health care altogether.
What the Affordable Care Act (ACA) did was expand taxpayer-funded care through Medicaid and Medicare while obliging individuals to purchase insurance at rates that continue to increase by large percentages year over year (Trish & Herring, 2015). The result was that health care became more accessible for more people—but it was anything but affordable for those who could technically "afford" to pay for it. Moreover, the manner of health care delivery remained questionable, as Goldhill (2009) has shown: instead of practicing preventive care, providers are incentivized to merely "treat" patients, conduct unnecessary tests, and overprescribe. The latter has contributed directly to the current opioid crisis (Rothstein, 2017). Thus, the Affordable Care Act has not done much to bring positive change to an already dysfunctional health care system; on the contrary, it has compounded existing problems by leading insurers to raise their premiums and deductibles to unprecedented levels. This paper argues that the pros do not outweigh the cons of the ACA.
Background: The ACA's Intended Goals
The Affordable Care Act was set in motion by President Obama to address several variables that hindered the treatment and prevention of illness due to lack of access to care (Jacobson-Vann, 2011). The ACA was meant to eliminate "lifetime and annual limits on insurance coverage" while obliging providers to engage in "preventive services," grant "access to health insurance for individuals with preexisting medical issues," and ensure that states had the "flexibility to establish health care programs for low income non-Medicaid eligible clients" (Jacobson-Vann, 2011, p. 100). These were the intended pros. While Rosenbaum (2011) lauded the ACA as a "watershed in U.S. public health policy," the reality was that health care had already become a profit-driven industry and the ACA did nothing to address this fundamental issue (Matthews & McGinty, 2010). This was the main con—and it was, and remains, a significant one, precisely because the profit-driven nature of the industry undermines any benefits the legislation was designed to create.
Why the Pros Don't Outweigh the Cons
The profit-driven nature of the health care industry was not addressed by the ACA, and therefore, regardless of what the ACA does to support preventive care, the underlying character of the industry remains oriented toward incentivized treatment—testing, medication, specialized procedures—rather than toward prevention.
As Goldhill (2009) points out, the ACA fails to improve health care because it fails to address the core problems of the U.S. system. The problem is not that there is too little access to health care; the problem is that the type of care provided is not truly appropriate because the motivation for care is profit-oriented rather than patient-oriented. This fact alone renders the industry problematic as a whole. Goldhill (2009) demonstrates clearly that the system is built on incentives that place too much emphasis on treatment rather than prevention—and even though the ACA incentivizes preventive care, it does not go nearly far enough in removing incentives tied to unnecessary and costly treatments. Goldhill (2009) further shows that many deaths result from a failure to practice preventive care, and therefore the essence of health care reform should focus on addressing that failure. The ACA, instead, focuses on treatment and government subsidies.
What appears to be a pro—government subsidization of health care—is actually a problem, because that subsidization guarantees the existence of a payer. When there is guaranteed demand for a service, prices rise; this is a basic principle of economics. Moreover, wherever government subsidizes an industry, prices tend to increase, as can be observed across sectors from education to housing.
Profit-Driven Care and the Insurance Mandate
What is worse is that the ACA's primary so-called "positive" is, in effect, a negative. The ACA focuses on expanding the role of insurance when it should have focused on reducing that role and eliminating the financing structures that have distorted the economic model of U.S. health care—structures that guarantee ever-rising prices while health quality declines. It is almost as though government were operating in concert with pharmaceutical companies to keep patients on drugs. Indeed, lawsuits against major pharmaceutical firms have accused drug makers of bearing responsibility for the opioid epidemic sweeping the United States (Semuels, 2017). The ACA has effectively subsidized this type of treatment.
Goldhill (2009) suggests that "the most important single step we can take toward truly reforming our system is to move away from comprehensive health insurance as the single model for financing care. And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system." Goldhill (2009) advocates a free-market approach to health care as well as direct subsidies to those who cannot afford care—rather than to those who provide it—which would arguably cut off the head of the profit-driven model that dominates the industry today. In other words, people need to be placed before profits, and a more consumer-centric health care system must be established. The ACA does not accomplish this; it attempts to play by the rules of the profit-driven industry.
The ACA was supposed to make health care more affordable and more universally available—but another significant con is that part of the law's justification rested on an individual mandate requiring all people to purchase insurance so that broader coverage could be achieved. The fact that not everyone complied—because prices remained too high and paying the penalty was less expensive than purchasing coverage, particularly for individuals who felt they did not need health care—illustrates how difficult it is to legislate a solution to rising health care costs. Health care providers have also struggled, as they must seek reimbursement for treating patients on Medicare. Smaller hospitals have been forced into consolidation, enabling major health care providers to develop market power and effective monopoly positions, thanks in part to the ACA. As Cutler and Morton (2013) note, "The Affordable Care Act (ACA) reduced the growth of Medicare hospital reimbursement by about 1.5 percentage points annually, the latest in a series of payment reductions stretching back many years. Cash-strapped state governments have reduced fees to inpatient institutions. The presumed revenue enhancement from expanded insurance coverage may not occur if states choose not to adopt the ACA Medicaid offer; 26 states have stayed out initially. These financial challenges will make it even more difficult for weaker hospitals to survive on their own" (p. 1967). In short, legislation ostensibly designed to help people access better insurance has primarily facilitated the consolidation of power in the marketplace and enabled health care organizations to develop the kind of market concentration that diminishes competition.
Conclusion
The ACA came into being with a host of pros and cons. The pros suggested that the law would help make care more accessible for those who could not afford it and that "preventive care" would be promoted, as Jacobson-Vann (2011) pointed out. The reality has proven otherwise: treatments and medications continue to represent the most subsidized form of care, while preventive medicine has fallen by the wayside. The fundamental character of the health care industry remains profit-driven, with profits placed before people rather than the reverse.
With care subsidized by government, costs have skyrocketed, and the insurance mandate has not helped, as premiums and deductibles have also risen sharply—making health insurance unaffordable for many people who do not have jobs offering the kinds of employer-sponsored coverage that became common decades ago. The reality is that the cons of the ACA outweigh the pros because, at a fundamental level, the ACA does nothing to address the profit-driven nature of the industry. In fact, it has done just the opposite: it has enabled major health companies to consolidate as smaller competitors are forced out, thus creating an environment ideal for monopoly formation.
References
Cutler, D., Morton, F. (2013). Hospitals, market share, and consolidation. JAMA, 310(18), 1964–1970.
Goldhill, D. (2009). How American health care killed my father. The Atlantic. Retrieved from https://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/
Jacobson-Vann, J. C. (2011). Slipping through the cracks of the breast and cervical cancer prevention and treatment act of 2000—a tragic case of failed access to care. Journal of Nursing Law, 14(3), 96–106.
Matthews, A. W., & McGinty, T. (2010). Physician panel prescribes the fees paid by Medicare. The Wall Street Journal.
Morrisey, M. (2013). Health insurance (2nd ed.). Chicago, IL: Health Administration Press.
Pope, C. (2014). How the Affordable Care Act fuels health care market consolidation. Retrieved from http://www.heritage.org/health-care-reform/report/how-the-affordable-care-act-fuels-health-care-market-consolidation
Rosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for public health policy and practice. Public Health Reports, 126(1), 130–135.
Rothstein, M. A. (2017). The opioid crisis and the need for compassion in pain management. American Journal of Public Health, 1253–1254.
Semuels, A. (2017). Are pharmaceutical companies to blame for the opioid epidemic? The Atlantic. Retrieved from https://www.theatlantic.com/business/archive/2017/06/lawsuit-pharmaceutical-companies-opioids/529020/
Trish, E. E., & Herring, B. J. (2015). How do health insurer market concentration and bargaining power with hospitals affect health insurance premiums? Journal of Health Economics, 42, 104–114.
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