The 2010 Affordable Care Act (ACA) is the first enacted U.S. law to attempt both comprehensive health care reform and universal medical coverage for Americans. The act seeks to fulfill a “triple aim”—expanded access to insurance, reduced costs, and improved healthcare quality. It represents a controversial law and therefore case that exposes changing rules, roles, and expectations regarding responsibility for the common good and for how “welfare” systems operate in the contemporary. I conducted a meso-level institutional analysis of the ACA’s design and implementation in California through in-depth interviews and secondary materials. My analysis shows that new meanings, new actors and new models are driving changes in the domains of health benefit provision, welfare and medical system governance and medical service delivery. I find evidence of increasing synthesis, i.e. integration and hybridity among state, market and society in its provision of social benefits, governance of the healthcare system, and delivery of medical services, rather than further polarization as frequently depicted in scholarship and public press accounts. Understanding the emergent approach to providing the common good that pays homage to both individuality and collective provision is important to these concepts that lie at the heart of what scholars, pundits, and the public claim is American exceptionalism. My analysis provides insight into the re-configuration of roles, relations and responsibilities instituted under the ACA that will shape individual health outcomes and ultimately the health of the nation for decades and generations to come.