What If? The States and Health Reform

State of Reform is proud to launch, in collaboration with the Univ of Washington School of Public Health – Health Policy Center Initiative , a series titled “What If: A Post-Supreme Court World.”  This is the fifth piece in a series of contributions hosted on our news site, by a range of authors, about the possibilities for health care in a still hypothetical world after a Supreme Court decision.

We know the fate of the Affordable Care Act (ACA) hinges on the choices of a group of nine justices and “…you can hear virtually any prediction you want…”[1]Given this uncertainty, what happens if we think about something certain instead? Specifically, regardless of the verdict, a crucial issue – maybe even the key feature – of the future of health care and public health is the fact that our states shoulder the responsibility of providing for the health of their residents.

The states are traditionally viewed as the level of government with authority over health, with support from the federal government.[2] In 2010, just over 22% of state spending was on Medicaid, the single largest portion of state spending.[3] Our states, though, vary in almost every aspect of public health infrastructures, policies, and outcomes.[4]

Although state spending on Medicaid averaged 22%, this share ranged from 7.3% in Wyoming to 34.4% in Montana.[5] The states also differ in insurance regulations and the practices of their regulators.[6] Furthermore, the degree to which eligible individuals enroll in Medicaid (adjusted for demographics) ranges from 43% in Arkansas and Louisiana to 82.8% in Massachusetts.[7]

This variation is not confined to budgets and bureaucrats; politicians add to the mix. Some states have begun to implement the health insurance exchange portion of the ACA, others are engaged in a planning process, and some are refraining from action.[8]

Moreover, at least 45 states considered over 200 bills and measures opposing the ACA in 2011 and already at least 157 similar bills are up this year.[9] Such varied levels of state support for the ACA suggest divergent policy choices that are crucial for health outcomes.

So Where Does that Leave Us?

Our states are diverse – leading to even more questions. What if the states aren’t up to the task or the federal government is unable to help? There are no specific answers; I do know the states need strength (in resources and capacity) as they deal with these challenges. Prior to the ACA, the unsustainable status quo had placed the states in dire situations.[10] The ACA with one hand helps the states and with the other expects even more of them. Thus, we await a verdict to see the path ahead.


[1] Altman D.  2012.  “Policy and Political Implications of the Supreme Court Case on the Affordable Care Act,” a Kaiser Family Foundation webcast. Available at http://www.kff.org/healthreform/scotus_aca_video.cfm

[2] Iglehart JK. 1999.  “Expenditures,”  The New England Journal of Medicine 340:70-76.

[3] The Fiscal Survey of States, Spring 2011. Available at http://www.nga.org/cms/home/special/col2-content/state-fiscal-information.html#.

[4]  The Kaiser Family Foundation, State Health Facts.  http://www.statehealthfacts.org/

[5] National Association of State Budget Officers. “Fiscal Year 2010 State Expenditure Report:  Examining Fiscal 2009-2011 State Spending,” Available at http://www.nasbo.org/sites/default/files/2010%20State%20Expenditure%20Report.pdf.

[6] Kofman M, and K Pollitz. 2006. “Health Insurance Regulation by States and the Federal Government: A Review of Current Approaches and Proposals for Change,” Georgetown University Health Policy Institute. Available at http://www.allhealth.org/briefingmaterials/HealthInsuranceReportKofmanandPollitz-95.pdf.

[7] Sommers BD, MR Tomasi, K Swartz, & AM Epstein. 2012 “Reasons for the Wide Variation in Medicaid Participation Rates Among States Hold Lessons for Coverage Expansion in 2014,” Health Affairs 31(5):909-919.

[8] Henry J. Kaiser Family Foundation Health Reform Source, “The States:  State Action Toward Creating Health Insurance Exchanges, as of April 13, 2012,”  available at http://healthreform.kff.org/The-States.aspx.

[9] Cauchi R. 2012. “State Legislation and Actions Challenging Certain Health Reforms, 2011-2012,” National Conference of State Legislatures, updated April 25, 2012. Available at http://www.ncsl.org/issues-research/health/state-laws-and-actions-challenging-aca.aspx.

[10] Garret B, M Buettgens, L Doan, I Headen, & J Holahan. 2012. “The Cost of Failure to Enact Health Reform: 2010-2020.” Urban Institute & Robert Wood Johnson Foundation Report, March 2010, available at http://www.urban.org/uploadedpdf/412049_cost_of_failure.pdf.