Has the Patient Protection and Affordable Care Act (ACA) finally ensured the longstanding goal of universal health care? Although the ACA helps many people, in several crucial respects it falls well short of a universal system. Rather than comprehensively cover all individuals in a single public program (eg, Medicare for those aged > 65 years), the ACA broadens coverage through a patchwork of provisions predicated on a continued major role for the private health insurance industry. Together, the provisions of the ACA significantly expand insurance coverage. However, even with the law fully implemented, the most serious shortcomings of our health-care system persist. Here we outline why the ACA falls short (with a focus on issues pertinent to pulmonary and critical care medicine) and propose an alternative, truly universal approach to health care in the United States.