Medicaid Expansion and Insurance Reform Under the Affordable Care Act: The New Federalism of Health Policy or the Same Old Same Old?

Abstract

Federalism in the United States is an ever-changing, push-pull landscape. The respective roles of the states and the federal government have evolved over time in most policy areas, with each level of government assuming more or less scope and influence. Federal law defines and redefines the relationship through statute and regulation. States test, through federally conferred program waivers and state law, the limits of federal law. This chapter explores whether the rejiggered state/federal responsibilities that resulted from the Patient Protection and Affordable Care Act of 2010 (PPACA, or the ACA) are similar to, or fundamentally different from, the shift from Aid for Families with Dependent Children (AFDC) to Temporary Aid for Needy Families (TANF). To examine ACA’s influence on state and federal roles, we will look at two specific policy areas: Medicaid and insurance regulation. The Medicaid expansion is a clear illustration of the strength of federal policymaking, even within a federalist relationship. State authority over health insurance regulation has been somewhat more clear-cut throughout the nation’s history, but not entirely lacking ambiguity. For the time being, we seem to be stuck with approaches to health insurance coverage and health insurance regulation that are neither state, nor federal, nor coherently federalist.