Long-Term Implications of Post-ACA Health Reform on State Health Care Policy
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and Laura A. Petersen, MD MPH1,2
1
Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, TX, USA; 2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
In the midst of the COVID-19 outbreak, health care reform has again taken a major role in the 2020 election, with Democrats weighing Medicare for All against extensions of the Affordable Care Act, while Republicans quietly seem to favor proposals that would eliminate much of the ACA and cut Medicaid. Although states play a major role in health care funding and administration, public and scholarly debates over these proposals have generally not addressed the potential disruption that reform proposals might create for the current state role in health care. We examine how potential reforms influence statefederal relations, and how outside factors like partisanship and exogenous shocks like the COVID-19 pandemic interact with underlying preferences of each level of government. All else equal, reforms that expand the ACA within its current framework would provide the least disruption for current arrangements and allow for smoother transitions for providers and patients, rather than the more radical restructuring proposed by Medicare for All or the cuts embodied in Republican plans.
J Gen Intern Med DOI: 10.1007/s11606-020-06168-4 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2020
the COVID-19 pandemic, health policy debates in B efore the US presidential election had focused on the proper role that private insurance plans in the US health system. Leftwing candidates for the Democratic nomination backed versions of Medicare for All, a new federal single-payer plan that would eventually eliminate most private insurance. In contrast, more moderate Democrats promoted strengthening the Affordable Care Act’s framework, which both expands existing public programs and subsidizes uninsured individuals purchasing regulated private plans. But debates over private versus public insurance neglect enduring divisions within the public sector. State and federal governments share responsibility for US public insurance
Received April 7, 2020 Accepted August 14, 2020
programs. This division of power dates prior to Medicare and Medicaid’s 1965 passage and has been renegotiated when reforms have filtered through American health care. Current proposals would add to this history, but like past reform efforts, both parties’ plans risk foundering on state elected officials’ two primary policy priorities: maximal federal funding and minimal federal restrictions on spending it.1 We review state roles in administering Medicaid and the ACA’s insurance exchanges, and explore how proposed reforms may alter the federal-state balance of power. We also examine how disruptive and contested those changes are likely to be. Finally, we discuss how factors like partisanship and
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