Efforts to meet this population's needs via an individual market for insurance have been inadequate over the past several decades. The ACA attempted to meet the insurance needs of this population in two ways: expand Medicaid to cover low-and moderate-income people at a more consistent income level across states and establish private individual insurance markets bolstered by subsidies for people with incomes above Medicaid eligibility levels. While this approach may have some practical problems, the point is the intent of the ACA is to build a system devoted to the principle that everyone should have insurance. The ACA was intended to fill in the major gaps - i.e., to move the nation toward the ideal of universal coverage.   

The ideal underlying many proposals for changing the ACA is quite different, and it is often phrased as "universal access to coverage." Universal access to coverage literally means that people will have access to buy coverage, but that insurance coverage is not an expected part of the responsibility that accompanies being an American.  

It is complicated, as our current system divides us into groups when it comes to insurance coverage according to age (Medicare) or employment status (where most of us get our insurance). And the financing mechanisms used for different groups have different values and distributional effects, tilting our views about how best, if at all, we should collectively provide financing for people who cannot afford insurance coverage. Both ways of viewing health insurance can find legitimate claim to deeply held American values, and these should be made explicit and discussed. Ideally, we can find a path forward that takes the best of these values and blends them in an effective system that serves the interest of us all, but especially of those among us who have been left without health insurance for too long.