The Patient Protection and Affordable Care Act of 2010 is the most significant reform of the U.S. healthcare system since Medicare and Medicaid in 1965. Health care is politically divisive in the Congress, the Supreme Court and in the states. This talk explores these divisions. This paper first provides a short history of health care financing in the United States. Second, I sketch the major provisions of the act and the politics that produced it. Third, I briefly describe the Supreme Court’s decision and speculate on the impact it might have on the regulation of health care financing and on constitutional law more generally. Ultimately, the future of health care reforms lies in the hands of the states, and is dependent upon the results of the elections on November 6.