The Supreme Court’s decision will make it much harder to extend health insurance to America’s poor. [View all]

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Just what problems have we solved now that the Affordable Care Act has been upheld? We should rightly celebrate that no American will be denied the ability to get health care because of a pre-existing condition, and that many children will remain on parents’ health plans for more time.

But at its heart, the bill was designed to extend private insurance to the largest (politically) possible number of the now 60 million uninsured Americans, and then expand the public safety net for the remainder. To do this, the ACA comprises a “three-legged stool” of policies: a mandate for employers and individuals to buy health insurance if they can afford it, a prohibition on insurers from barring any buyers, and, finally, a massive expansion of free health care for the poor.

According to optimistic projections from the Congressional Budget Office, the ACA as written would only halve the number of uninsured—from 60 million down to 30 million—by 2022. Thus, even with the ACA safe, one-half of all currently uninsured Americans are still projected to lack coverage.

This is why it was difficult for me to care greatly about the presence or absence of the individual mandate, which was at the heart of the Supreme Court case. In all of Massachusetts, the laboratory from which the ACA sprung, only about 20,000 people—which is less than 0.3 percent of the population—were assessed penalties for not buying insurance, penalties that totalled less than $20 million. Forcing people to buy insurance did precious little; those without private insurance are mostly those who couldn’t afford it anyway.

So what does the ACA really do to expand coverage? Again, it’s worth examining Massachusetts. As I wrote back in 2010, the state reforms correlated with a drop in the percentage of the uninsured from 6.4 percent to 2.4 percent, or a gain in coverage for 233,000 citizens. Over this time, state Medicaid rolls ballooned by 276,000 people, indicating that the real driver for expanding coverage was almost exclusively a free giveaway of health care—that is, the third part of the three-legged stool. (Enrollment in private plans grew by only a paltry 2 percent.)

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