The November 8, 2016, election propelled a single party to gain control of the presidency and both houses of congress. Similar to when the Affordable Care Act (ACA) was enacted, this provided an opportunity to reshape American health care without the need for bipartisan consensus. So far, these attempts have been unsuccessful. This paper explains the actual terms of the ACA, why some aspects were controversial, where it has succeeded and where it has failed, the unsuccessful repeal efforts to date, what may come next, and that, despite the focus on the insurance exchanges, US health care and clinical gastroenterology’s core challenge is controlling costs.