The Affordable Care Act (ACA) has accomplished much that its drafters intended. There is considerable evidence of increased access to health care and reduced medical debt. But there is growing concern about affordability of health insurance coverage for middle-income working-age consumers — those whose household income exceeds 400 percent of the federal poverty level (about $100,000 for a family of four) — who do not have coverage through their work. This is virtually the only group of Americans who, when insured, do not receive some form of direct federal financial assistance or tax subsidies for health care coverage.