The ACA’s Choice Problem

22 Pages Posted: 3 Sep 2020

See all articles by Allison K. Hoffman

Allison K. Hoffman

University of Pennsylvania Carey Law School

Date Written: August 2020


The Affordable Care Act (ACA) is in many ways a success. Millions more Americans now have access to health care, and the ACA catalyzed advances in health care delivery reform. Simultaneously, it has reinforced and bolstered a problem at the heart of American health policy and regulation: a love affair with choice. The ACA’s insurance reforms doubled down on the particularly American obsession with choice. This article describes three ways in which that doubling down is problematic for the future of US health policy. First, pragmatically, health policy theory predicts that choice among health plans will produce tangible benefits that it does not actually produce. Most people do not like choosing among health plan options, and many people—even if well-educated and knowledgeable—do not make good choices. Second, creating the regulatory structures to support these choices built and reinforced a massive market bureaucracy. Finally, and most important, philosophically and sociologically the ACA reinforces the idea that the goal of health regulation should be to preserve choice, even when that choice is empty. This vicious cycle seems likely to persist, based on the Democratic debates leading up to the 2020 presidential election.

Keywords: Health care policy, Affordable Care Act, ACA, choice of health plan, managed competition, health insurance, market bureaucracy, sociological problem with choice of plan, health reform, 2020 elections

Suggested Citation

Hoffman, Allison K., The ACA’s Choice Problem (August 2020). Journal of Health Politics, Policy and Law, Vol. 45, P. 501, 2020., U of Penn Law School, Public Law Research Paper No. 20-29, Available at SSRN:

Allison K. Hoffman (Contact Author)

University of Pennsylvania Carey Law School ( email )

3501 Sansom Street
Philadelphia, PA 19104
United States


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