Healthcare: Federal or State Domain? Roberto Mejias, NP, RNFA

Here's the problem...

On March 23, 2010, President Obama enacted the Affordable Care Act, otherwise known as Obamacare, in an effort to overhaul the U.S. Healthcare system and make health insurance affordable to everyone. To date, the law has caused a significant reduction in the number and percentage of people without health insurance. In fact, the CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% during the January–June 2016 period. Despite the improvements, Obamacare has sparked several debates most notably who should control healthcare systems? The federal government or individual states?

This is what as been going on...

Obamacare sought to empower states to create their own healthcare platforms that would enroll and offer affordable health insurance to all. Currently, there are 14 states and the District of Columbia that operate their own exchanges, but running a state healthcare exchange is not without challenges and some states have struggled to make the exchanges work. The cost of setting up and running the platforms has been an obstacle particularly for smaller states that lack the financial resources to do so. The annual operating costs of state platforms has, in some cases, exceeded ten million dollars. The federal government administers a health exchange in the remaining 36 states who are either unable or have chosen not to operate an exchange.

There is, however, an intrinsic benefit to state controlled healthcare systems. State run exchanges can enroll families on a local level, certify health insurance plans, monitoring rates and reimbursements, and oversee the Children's Health Insurance Program (CHIP) and related services on an individualized state level that works best for the state.

Who are the stakeholders in all of this?

The stakeholders in this debate include the individual state and it's citizens, local government and politicians, health insurance providers, primary and specialty care providers, and the Children's Health Insurance Plan.

But there is a solution...

Beginning in 2017, individual states can seek federal funding for “alternate coverage reform” under Section 1332 of the Affordable Care Act. The federal funding will allow the 14 current state exchanges to reform Obamacare and revamp their individual state healthcare exchanges. It is estimated that there are hundreds of millions of dollars available to each of these states if they seek waivers under Section 1332 of the Affordable Care Act. The funds could be used to save failing state systems by helping them upgrade their platforms and revamp their current method of operation. The federal funds can also be used to help the remaining 36 states to start up new exchanges.

What needs to be done next...

State representatives must petition the federal government for funding under Section 1332 of the Affordable Care Act. Likewise, state infrastructures need to be poised to utilize the available funds to upgrade existing state systems, enroll families, and ensure quality health care and insurance providers are available.

How can I help?

As a Doctor of Nursing Practice, I can help by practicing in an Obamacare enrolled provider facility. I can also encourage my patients in practice to enroll in Obamacare if they are not already enrolled. And finally, I can write to my local and state government officials and lobby on behalf of Obamacare.


Corlette, S. C., Lucia, K. W., & Giovannelli, J. G. (2014). Implementing the Affordable Care Act: State Action to Reform the Individual Health Insurance Market. doi:10.15868/socialsector.25003

Mccarthy, M. (2014). More than 4.2 million have signed up for US health insurance on Affordable Care Act exchanges. Bmj, 348(Mar14 3). doi:10.1136/bmj.g2140

Noh, S., & Krane, D. (2016). Implementing the Affordable Care Act Health Insurance Exchanges: State Government Choices and Policy Outcomes. Publius: The Journal of Federalism, 46(3), 416-440. doi:10.1093/publius/pjw010

Created By
Roberto Mejias


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