I spend a lot of time thinking about the Affordable Care Act (ACA) and how it will affect the sickest, most vulnerable, and therefore most costly patients in the U.S. I practice in the relatively new interdisciplinary specialty of palliative medicine, which aims to improve the quality of life of people with serious, complex illnesses. So all of my patients are living with profound fatigue, pain, shortness of breath, financial and family stresses, and mountains of worry. The ACA’s focus on quality over quantity could increase attention to the needs of such patients. Or, with its twin focus on reducing out-of-control spending, the ACA might prompt a race to the bottom, as necessary — but costly — treatments are summarily avoided.