DV Journal

During his budget address, Gov. Josh Shapiro claimed the Affordable Care Act (ACA) “is working for Pennsylvanians.” So, is he right? Judging by his 2025–26 budget plan, even the governor may doubt the ACA truly works for Pennsylvanians.

If it’s working, why do rural hospitals need cash infusions? Shapiro proposes $10 million for rural hospitals and another $20 million for “hospital partners” for patient safety and services. Meanwhile, no evidence exists the ACA has slowed rural hospital closures.

If it’s working, why is there a statewide care provider shortage? A fact Shapiro acknowledged in his address. Notably, his budget adds $10 million above the existing $8 million to repay loans for primary care medical professionals.

If it’s working, why would the state deny competing insurance models? Association Health Plans (AHPs) allow companies to pool funds and reduce employee health insurance costs. Yet, Pennsylvania ostensibly banned AHPs. In 2019, Pennsylvania joined 10 other states and the District of Colombia to sue the U.S. Department of Labor to reverse the agency’s new rule expanding AHPs.

So, no, ACA isn’t working for Pennsylvanians—full stop. Shapiro’s calls for so many added subsidies and mandates to prop up our health care system prove its shortcomings.

Moreover, ACA is costly. Nationally, exchange premiums doubled between 2013 and 2017. The same holds true in Pennsylvania: Premiums increased 6 percent statewide this year.

ACA cheerleaders point to increased enrollment. Pennie—Pennsylvania’s state-level version of ACA—added 500,000 new enrollments this year. However, when extra federal tax credits expire, enrollees can expect a whopping 81 percent premium increase by 2026. Last year, Shapiro attempted to intercept this financial shortfall by introducing a new statewide subsidy to make Pennie plans more affordable. (Again, is this system really working?)

Health care is more than just access. Possessing an insurance card doesn’t guarantee affordable, high-quality care. This is especially true with publicly subsidized programs. Public insurance programs increase the amount of health care used; however, their improvements to overall health are, at best, overstated and, at worst, fabricated.

ACA hasn’t improved the overall health of the nation. Before 2014 (when ACA began enrolling the uninsured), life expectancy grew by about 1.5 years per decade. From 2014 to 2017, life expectancy dropped annually—the first time in 100 years. This decline was even more drastic in states that adopted the ACA Medicaid expansion compared to states that didn’t.

Meanwhile, families continue to struggle with soaring insurance premiums. From 2019 to 2024, KFF, formerly known as the Kaiser Family Foundation, found the average premium for family coverage increased 24 percent. About half of insured adults say it’s difficult to afford coverage. One in four Americans skip or postpone treatment because of cost.

In true broken-clock fashion, Shapiro was “right” about two policies to make health care more affordable.

The first is price transparency. Only 30 percent of Pennsylvania hospitals comply with a federal mandate to publish service prices. Holding providers accountable would empower patients to shop around and avoid the sticker shock of unexpected medical bills.

Shapiro also suggested broadening the scope of practice for caregivers to solve health care labor shortages. Nurse practitioners (NPs) have the skills and training to diagnose and treat patients. However, Pennsylvania law keeps these talented professionals sidelined by requiring expensive collaborative physician agreements. Granting NPs full practice authority would increase the supply of primary care professionals, especially in Pennsylvania’s underserved rural areas. Pennsylvania houses about 16,000 NPs. With full practice authority, one NP could serve an additional 109 patients.

Pennsylvania lawmakers must also embrace competition and adopt alternative models of coverage. AHPs, for example, provide millions of Americans with cost-effective, high-quality coverage for a fraction of the cost. The Foundation for Government Accountability found that AHPs provide up to 29 percent in average savings. Pennsylvania must join the 30 states that allow AHPs. Like Pennie, these plans can cover everything from preventative care to emergency care.

Shapiro’s proposal to codify ACA into state law is another bait-and-switch maneuver. The ACA’s start in 2010 may have fooled some. But after more than two decades, Pennsylvanians want a more personal, affordable, higher-quality level of care—things the ACA has failed to provide. Harrisburg must stop subsidizing failed programs and enact laws that empower Pennsylvanians to personalize their care.