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July_2013Daniel Béland and Alex Waddan

July 2013

In the early spring of 2010, after a long and divisive political battle, Democratic President Barack Obama signed into law the Patient Protection and Affordable Care Act (PPACA). The most ambitious and expansive federal health care reform adopted in the United States since the mid-1960s, PPACA features complex provisions that are being gradually phased in, which means full implementation of the legislation is only scheduled to be completed by 2019. Considering its sheer scope, this legislation will have a direct and powerful impact on federalism in the United States.

The objective of this short paper is to explore some of the emerging features about how the law will work from the perspective of the federal government and of the 50 states. The paper begins with a brief overview of the relationship between federalism and health care policy in the United States, which is followed by an analysis of the actual content of PPACA, as it impacts federal-state relations. This discussion leads to remarks about opposition to PPACA emanating from Republican governors and the legal challenge they helped orchestrate. The Supreme Court finally recognized the overall constitutionality of the legislation in late June 2012. However, the judgment did rule aspects of the law, regarding the proposed expansion of the existing Medicaid program, unconstitutional in a manner which had important implications for the balance of power between the federal government and the states, and which might undo some of the original intent of the PPACA.

The final substantive section examines the challenges stemming from the implementation of PPACA in the context of U.S. federalism and the manner in which some states have decided not to cooperate fully in the ongoing development of this reform package.

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