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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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What the ACA’s Repeal Means for States

Congressional Republicans have taken the first steps to repealing the Affordable Care Act (ACA), despite lack of a clear consensus on a replacement plan. Attention is now focused on what happens in Washington; however, whatever Congress does will reverberate far beyond the nation’s capital. Many of the ACA’s major benefits are delivered at the state level through health insurance exchanges and Medicaid, and states have received substantial federal money from the ACA. What could the ACA’s repeal and Republican policy initiatives mean for states?

The concept of health insurance exchanges as purchasing pools for the uninsured and small businesses was once a popular idea for conservatives drawn to the model of consumers choosing among competing private plans. But as the debate over the ACA’s implementation heated up, exchanges became a controversial partisan issue. Many GOP-led states ultimately refused to implement them, both in protest against Obamacare and in the hopes of undermining it. Consequently, only 16 states and the District of Columbia run their own ACA insurance Marketplaces, with the federal government operating them elsewhere. Eliminating the exchanges would be enormously frustrating to the state leaders who spent considerable time and resources to implement them.

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