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As Changes to the ACA Remain Uncertain, the American System of Federalism Allows States to Move Forward with Healthcare Initiatives

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Suzanne Discenza
April 25, 2017

This article is third in a series of monthly columns exploring the future of current and pending government-sponsored healthcare policies and programs.

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It would seem relatively easy at this point to merely write a summary of the attempted but failed repeal and replacement of the Affordable Care Act (ACA) by Congress last month. But plans are moving forward quickly as republican members of Congress try again to repeal the law and it is too soon to speculate on the ultimate outcome of this effort. According to many policy wonks and political pundits alike, it may be too much of a stretch for the ACA to be repealed in full due to the popularity of so many of its provisions, while at the same time most health policy analysts agree there are certainly less sustainable provisions that may require major revisions or outright replacement.

The current article in this series, as originally conceptualized, will remain focused on what some individual state legislative bodies have been doing to ensure affordable and more comprehensive health care services for their residents in the face of national uncertainty. The larger significance of these efforts is that the American system of “federalism,” conceived by the American Founding Fathers to allow states to share power with the Federal government, is alive and well in the provision of health services to U.S. citizens. While recent or pending legislative initiatives by states to increase healthcare access or reign in costs abound across the country, examples from two particularly active states will be provided to demonstrate the breadth of these efforts.

We have heard much about the ongoing health initiatives in the state of Massachusetts on behalf of its residents, including legal immigrants, during the past decade especially. In fact, Massachusetts health reform initiatives are often credited as having provided the prototype for many national reform measures in the Affordable Care Act, including state health insurance exchanges, minimum coverage standards and elimination of pre-existing condition exclusions. On its website, the Massachusetts Executive Office of Health and Human Services boasts the state now has a 98 percent health insurance coverage rate, while at the same time reform measures have “not been a budget buster,” incurring a relatively modest increase in net spending of “just over one percent of the state budget” in FY 2010. Not resting on its laurels, the state in 2016 launched a comprehensive public-private digital health partnership to further identify market gaps, reduce healthcare costs and improve patient care.

California has been another leader in enacting healthcare reforms to expand coverage for its residents. In June 2016, California initiated a push to become the first state to offer health insurance to undocumented residents through its state health exchange, “Covered California,” but withdrew its request in January 2017 to waive Federal requirements of coverage for only citizens and legal residents with what it considered an unreceptive change in administration. In September 2016, a new consumer law was enacted in the state limiting “balance billing” or “surprise medical bills” from out-of-network providers when a patient receives care at in-network facilities, following on the heels of a similar law enacted in the state of New York earlier in the year. In March 2017, Bay area legislators began the push to limit emergency room closures in nonprofit hospitals due to the “crisis-level” shortage of urgent care services. Finally, while Colorado voters failed in November 2016 to pass Amendment 69 that would have established a universal health-care system in the state, California lawmakers are currently crafting a bill to push single payer health care for all Californians, regardless of immigration status, using a state waiver provision of the ACA.

Regarding the use of “innovation waivers” to allow states to modify their healthcare laws to meet the unique needs of their residents, U.S. News & World Report on March 16, 2017, highlighted a little publicized executive order signed by President Donald Trump on Inauguration Day stating the federal government should “provide greater flexibility to states and cooperate with them in implementing healthcare programs.” Seemingly making good on this promise, on March 13 the administration again urged the use by states of “innovation waivers under Obamacare,” and on March 15 top health officials from the U.S. Department of Health and Human Services “cosigned a letter to governors saying that they intended to work with states to improve Medicaid programs” serving low income citizens.

In summary, while Congress continues to capture the lion’s share of media attention concerning the divisive topic of repeal of the Affordable Care Act, individual states are more quietly going about the business of enacting legislation to meet the health needs of their residents. Bolstered by the Trump administration’s support in devolving health policy issues to the states, allowing the American system of federalism to take its course in issues of health policy may well be the best solution yet to bring the nation together.


Author: Suzanne Discenza currently serves as a lecturer in the School of Public Affairs at the University of Colorado Denver and as an adjunct professor in Public Administration and Healthcare Management at Park University.  Former Director of the MHA Program at Park, she also serves on the ASPA National Council and as Past Chair of the Health Policy Forum of AUPHA.

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One Response to As Changes to the ACA Remain Uncertain, the American System of Federalism Allows States to Move Forward with Healthcare Initiatives

  1. Dr. Eric Click Reply

    April 25, 2017 at 7:07 pm

    Great and timely work by my colleague here!

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