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The enactment of the Patient Protection and Affordable Care Act (ACA) in 2010 was full of surprising puzzles. First, how does a market-based reform intended to create competition among health plans for health care consumers get labeled as a liberal socialist reform? Second, given that the ACA passed with no Republican votes, is it true that Democrats did not compromise and that Republican proposals were not included in the ACA? Third, with employer-based health insurance covering the majority of Americans, why were major US employers so conspicuously silent on the most significant health care legislation since the passage of Medicare and Medicaid? Fourth, given that Republican-led states were so adamantly against the federal ACA mandate to expand Medicaid, because of concerns about federal ‘‘coercion’’ over state discretion, why have the vast majority of Republican-led states abdicated their right to establish a state-controlled health insurance marketplace in favor of a federally controlled marketplace? Fifth, does the ACA’s creation of the Patient-Centered Outcomes Research Institute (PCORI) provide legitimate hope that health care decisions will be based on rational comparative-effectiveness research? And, finally, how should state health insurance marketplaces be structured and governed to fulfill their promise of adequate, affordable, and meaningful consumer choice? All these questions and more are addressed in this issue. Jill Quadagno’s article, ‘‘Right-Wing Conspiracy? Socialist Plot?,’’ provides a detailed political history of the most controversial component of the ACA—the individual mandate—from its origins as a Republican policy idea starting in 1993 to the Democratically led passage of Obamacare in

Clarifying ACA Puzzles and Looking for Hope