This chapter critically examines the Affordable Care Act (ACA), exploring why it has fallen short of its goal to make health care more affordable while reducing the number of uninsured individuals. The ACA succeeded in expanding coverage through Medicaid and subsidized exchanges but failed to control rising health care costs or achieve anticipated enrollment rates, especially among younger, healthier populations. Key challenges include a lack of pricing transparency, adverse selection, and misaligned incentives for patients, providers, and insurers. The ACA’s complexity and public confusion over insurance programs further hinder its effectiveness. Despite its shortcomings, the ACA set the stage for reforms, underscoring the need for cost containment alongside expanded coverage to prevent fiscal strain. Emerging technologies like artificial intelligence and blockchain offer promising pathways for improving diagnostic accuracy, enhancing transparency, and optimizing operations. These innovations, coupled with bipartisan collaboration, are essential to transforming US health care into a more accessible, affordable, and sustainable system.