What Is Federalism in Healthcare For?

Abstract

The Affordable Care Act (ACA) offers a window into modem American federalism-and modern American nationalism-in action. The ACA's federalism is defined not by separation between state and federal, but rather by a national structure that invites state-led implementation. As it turns out, that structure was only a starting point for a remarkably dynamic and adaptive implementation process that has generated new state-federal arrangements. States move back and forth between different structural models vis-a-vis the federal government; internal state politics produce different state choices; states copy, compete, and cooperate with each other; and negotiation with federal counterparts is a near constant. These characteristics have endured through the change in presidential administration.

This Article presents the results of a study that tracked the details of the ACA's federalism related implementation from 2012 to 2017. Among the questions that motivated the project: Does the ACA actually effectuate "federalism," and what are federalism's key attributes when entwined with national statutory implementation? A federal law on the scale of the ACA presented a rare opportunity to investigate implementation from a statute's very beginning and to provide the concrete detail often wanting in federalism scholarship.