Affordable Care Act Balances Responsibility of States and Federal Government

The fierce national debate over healthcare reform reveals deep divisions over the appropriate roles of the federal and state governments. For example, while Senator Bernie Sanders (I-VT) calls for expanding the federal Medicare program to cover all Americans, the Trump administration pushes for the states to have far greater authority. However, according to Michael Sparer, JD, PhD, chair of health policy and management at the Columbia Mailman School of Public Health, the Affordable Care Act (ACA) points towards a more effective intergovernmental partnership, one in which the states have significant policy and administrative discretion, bounded by strong national standards designed to limit unacceptable inequities.

In a policy paper titled “Federalism and the ACA: Lessons for the 2020 Health Policy Debate,” in a special issue of the journal Health Affairs, Professor Sparer writes: “States are too prominent and too engaged in every aspect of the nation’s health care system not to insist on playing an important ongoing role.” Proposals to eliminate a significant state role are both unlikely to be enacted and at odds with 250 years of American history. But he adds that future reforms also need strong national standards to guarantee the desired policy outcome (such as universal coverage) and to limit unacceptable inter-state inequities.

The ACA offers several models for combining centralized and state-based approaches for policymakers to develop the next generation of health reform, notes Sparer, and each of them could achieve universal coverage without eliminating the private insurance system. Indeed, rather than abandoning the ACA, reformers ought to recognize that the law suggests “the sort of intergovernmental partnership that just might lead to a U.S. version of affordable universal coverage.”

On March 10th Professor Sparer will take part in a briefing in Washington hosted by the journal.