How 60 years of change realigned US health law’s role
LDI senior fellow and Penn Carey law professor Allison Hoffman explains that as private entities have become embedded in public programs like Medicare Advantage and the Affordable Care Act marketplaces, they now shape health care delivery while resisting oversight, driving up costs, and complicating efforts to improve care quality.
2 min. read
Over the last 60 years, the U.S. government’s role in health care has shifted from that of a direct provider and payer through Medicare and Medicaid to a regulator increasingly reliant on private insurers and providers to deliver services. Courts and corporate influence have constrained its regulatory power, according to a new analysis by LDI senior fellow and law professor at Penn Carey Law Allison Hoffman.
In a December 2025 article in the Journal of Health Politics, Policy and Law, Hoffman and her co-author point out that as private entities have become deeply embedded in public programs like Medicare Advantage and the Affordable Care Act marketplaces, they now shape health care delivery while resisting oversight, driving up costs and complicating efforts to improve care quality. The authors further note that recent Supreme Court decisions have limited the government’s ability to regulate, while the Employee Retirement Income Security Act and other legal restrictions block states from stepping in, leaving the future of health law caught between weakening federal and state authority and strengthening private control.
Their article argues that the evolving power dynamic they document affects health care financing, access, quality, and cost, with entrenched private sector actors shaping outcomes within programs intended to serve public interests rather than profit goals.
“The dramatic evolution in American health law and the role of government in recent decades suggests that health law will continue to rest on unstable ground,” Hoffman writes. Overall, the authors conclude, “The levers that have shifted the government out of the role of market participant and that have undermined the force of the government’s regulatory authority are hard to reverse. Once private parties gain significant influence over large federal programs, like Medicare and Medicaid, wresting control back is a herculean task. And once the Supreme Court has gone down a pathway of scrutinizing agency actions more aggressively, it is hard to return to a regime of deference to reasonable agency actions.”
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