States are the Key to Both Strengthening and Replacing the Affordable Care Act | Health Care Reform | JAMA Forum Archive | JAMA Network
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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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States are the Key to Both Strengthening and Replacing the Affordable Care Act

The prevailing view among health policy experts seems to be that today’s political polarization means years of trench warfare are ahead for the Affordable Care Act (ACA). According to this gloomy view, a messy stalemate is assured for years to come.

I’m not so sure. I believe the states can and will become the vehicle—both politically and technically—for an era of progress in which each political side can genuinely declare victory.

For its part, the Obama Administration has been granting waivers from regulations to encourage resistant conservative and Republican states to adopt some variation of Medicaid expansion and other features of the ACA. States like Arkansas, Indiana, Ohio, and Pennsylvania are among those at various stages of using or negotiating such waivers. A recent report on ACA implementation in the South indicates that several states opposing the ACA emphasize practical issues rather than ideological opposition. Moreover, by being open to a “private option” for Medicaid coverage, or new forms of health exchange, even states like Texas might embrace versions of some of the ACA’s core coverage objectives if granted adequate waivers.

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