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ABSTRACT Establishing a balance of power between states and the federal government has defined the American Republic since its inception. This conflict has played out in sharp relief with the implementation of the Affordable care Act. This article describes the interplay between state and federal governments in the implementation of the act in three areas: the expansion of eligibility for Medicaid, implementation of the insurance Marketplaces, and regulation of insurers. The experience shows that states are intimately involved in health care and that useful policy and fiscal advantages can result from that involvement. However, strong national standards are critical to preventing partisan politics from trumping the health policy process.
To accomplish its substantive goals- to reduce the number of uninsured people, control costs, and make the health care system more effective- the Affordable Care Act (ACA) added new rules and organizational structures to an already complicated and constantly evolving intergovernmental health care partnership. This article reviews how federalism (the sharing of power between different levels of government) influenced the implementation of the ACA, with a particular focus on efforts to aid the uninsured.
In some cases, the answer seems obvious: The law as written required each state to expand eligibility for its Medicaid program, but the Supreme Court struck down that mandate as unconstitutional, and more than a dozen states have refused to adopt the eligibility expansion. In this case, "partisan federalism"1 has stymied the original legislative intent and undermined the goal of moving the country closer to universal coverage.
In other cases, however, the law's federalist structure had a different impact, offering a partial antidote to the partisanship that surrounds the ACA by providing Republican officials in some states with political cover to implement unpopular parts of the law and later offering Democratic officials a way to protect the law against concerted attacks by the administration of President Donald Trump. As a result, several Republican-dominated states adopted the Medicaid expansion in ways not originally envisioned by the law, several Democratic-dominated states enacted rules that counteract recent efforts to weaken the law's consumer protections, and states across the political spectrum have worked with federal officials to divide the tasks involved in running an insurance exchange, or Marketplace. This version of ACA federalism is consistent...