Health Insurance, Risk, and Responsibility after the Patient Protection and Affordable Care Act

Affordable Care Act embodies a new social contract of health
care solidarity through private ownership, markets, choice, and individual
responsibility, with government as the insurer for the elderly and the
poor. The new health care social contract reflects a
“fair share” approach to health care financing. This approach
largely rejects the actuarial fairness vision of what constitutes a
fair share while pointing toward a new responsibility to be as healthy
as you can. This new responsibility reflects the influence of
health economics and health ethics. There are challenges to achieving
the solidarity through individual responsibility envisioned in the Act—most
significantly ”risk classification by design”
and non-compliance with the mandates—but the Act contains regulatory
tools that the states, the new Exchanges, and the Department of Health
and Human Services can use to address these challenges. This Article
provides a high level overview of the distribution of health insurance
risk and responsibility after the Affordable Care Act and describes
how the Act reforms the key institutions that perform that distribution:
Medicare, Medicaid, the large-group health insurance market, and the
individual and small-group health insurance market.

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