“The ACA is vulnerable to the availability of resources at many other levels. The United States has a large national deficit for which the federal government must account. The states find themselves with inadequate financial resources. Many states cannot legally run a deficit and this limits their ability to participate in many of the ACA programmes that require their funding (Weissert & Weissert, 2006).

“The federal budget compromise enacted by Congress in March 2011 reduced funding for many programmes as part of a package of budget cuts required to ensure that the federal government could continue to function in the face of almost unbridgeable differences between Democrats and Republicans. The Obama Administration “diverted some of the $11 billion set aside in the health-overhaul law for health center expansion initiatives and instead used it to keep the existing centers operating at current levels” (Galewitz, 2011b). This could result in a shortage of health-care providers to serve the newly insured in 2014, though some research suggests that the newly insured are likely to continue to use the safety-net providers to which they are accustomed (Katz, 2011).

“Negotiations over the “fiscal cliff” crisis in December 2012 led to important reductions in the ACA (Kliff, 2013). The ACA’s carefully constructed budget-neutral accounting is vulnerable on many counts including aggressive stakeholder action. Stakeholders continue to lobby Congress for changes in the legislation. In some cases they would like to revise the commitments that they made to cost reductions during the negotiations that went on while the law was making its way through Congress. However, even small, unanticipated changes in health system financing threaten to upset the ACA’s negotiated balance sheet
(Pollack, 2011).”

Source: Rice T, Rosenau P, Unruh LY, Barnes AJ, Saltman RB, van Ginneken E. United States of America: Health system review. Health Systems in Transition, 2013; 15(3): 1– 431.