What’s YOUR state doing to save the ACA?

What’s YOUR state doing to save the ACA?


Key points

Last week, California lawmakers went on a marathon voting session, presenting or passing a whopping 19 healthcare-related bills. Most of these either repair damage done to the Affordable Care Act, protect existing provisions from being ripped away, or expand on the law. A few aren’t directly related to the ACA itself but will have indirect benefits to it in the future.

California isn’t the only state doing this, though. More than a dozen states have passed at least ten or more measures to repair, protect or strengthen the ACA since it went into effect, and five states have passed at least ten or more in just the 2 ½ years since Donald Trump took office (and the GOP’s war on the ACA went into overdrive).

Stiff resistance from the start

When the Patient Protection and Affordable Care Act was signed into law in 2010, it had squeaked through Congress by the skin of its teeth. Like every other law impacting millions of people and billions of dollars, there were compromises made along the way in order to secure the votes needed to just barely get it passed.

With most legislation, those opposed to a new law usually spend a couple of years grumbling about its shortcomings. Eventually, they realize that it’s probably here to stay, so they might as well try and make the best out of it by working with the proponents to fix problems, shore up weak spots and generally make the law work better in the future.

With the ACA, that didn’t happen. For seven years, supporters of the law had to watch in frustration as flaws, shortcomings and gaps in the ACA – some of which would be easily fixable with a few slight tweaks to the wording and/or formulas – were left to fester. At the same time, supporters watched as other parts of the law – which were working properly – were undermined.

All-out war on the ACA

The situation worsened in 2017, of course, as the Trump Administration and Congressional Republicans declared all-out war on the ACA and took numerous steps to weaken, sabotage or mutate various ACA provisions. Most notably, they pursued the elimination of the individual mandate, the cut off of cost sharing reduction (CSR) reimbursement payments, the expansion of non-ACA-compliant short-term plans and the encouragement of work requirements for Medicaid expansion.

In 2019, having retaken the U.S. House for the first time since losing it in 2010, Democrats are now finally in a position to pass any number of bills to repair, protect, strengthen and expand the ACA that they want to. But to date, their legislative efforts have died in the GOP-held Senate (or would be vetoed by Trump if they somehow managed to get past Mitch McConnell). Any significant improvements to the ACA at the federal level are likely destined to go nowhere until at least 2021, while the shortcomings and sabotage continue to take their toll.

Three ways states are fighting back to save the ACA

That’s where the states come in. There’s a lot which can be done to replicate or even improve upon the ACA’s requirements at the state level – and some states have been doing just that. (It’s important to note that some states had some of the following provisions in place before the Affordable Care Act. In fact, some ACA provisions were actually inspired by state-level legislation, even beyond Massachusetts’ “RomneyCare” law.)

Generally speaking, there are three types of measures states can take to push back – and strengthen the ACA:

State-level efforts to strengthen and preserve ACA's provisions

Click on this spreadsheet for details of state-level efforts to preserve the Affordable Care Act’s provisions.

ACA PROTECTIONS: The easiest steps states can take involve simply codifying some of the ACA’s consumer protections at the state level – just in case the insane Texas vs. Azar lawsuit ends up tearing down the entire law en masse. The worst-case scenario for that likely wouldn’t happen until the end of 2020, however, making it relatively painless for states to pass “just in case” legislation. If the ACA isn’t repealed, those state laws won’t ever be triggered anyway … and none of them cost a dime in the meantime.

ACA REPAIRS: Repairs include restoring or otherwise mitigating the damage already done to the law: Repeal of the individual mandate; the cut-off of CSR reimbursements; the expansion of short-term plans; the shortening of the open enrollment period and the like.

ACA IMPROVEMENTS: These are actions which either fix problems the ACA had in the first place or take the law to the next step. This includes things like expanding financial subsidies, codifying restrictions on short-term and other non-ACA compliant policies or adding mandatory protections or services to insurance policies.

Fourteen states going all out to preserve the ACA

State legislative efforts to preserve or strengthen provisions of the Affordable Care Act

View a PDF chart showing an overview of state legislative efforts to preserve or strengthen provisions of the Affordable Care Act.

In all, I’ve categorized 36 different measures states can take. Every state in the country – even most GOP-held states – have at least one of these provisions, with one exception: Mississippi, which scores zero to date.

Here are the 14 states that have either locked in – or made progress toward – at least ten provisions that will help preserve the ACA’s impact.

I’ve linked to a reliable source for every item below; many are via The Commonwealth Fund.

View my spreadsheet detailing the measures state by state. (I’ll update it as states make progress on implementation of their individual measures.

California – 12 provisions enacted, 5 in progress, 8 extras

California is clearly setting the pace for ACA preservation. As noted above, the state’s lawmakers just recently passed 19 bills that repair damage done to the Affordable Care Act.

The state has already …

In addition, California is in the process of …

… and is considering these 8 ‘bonus’ measures as well …

New Jersey – 9 provisions in place, 9 in progress

New Jersey has already …

… and is in the process of …

Massachusetts – 17 provisions enacted

Massachusetts has already …

Rhode Island – 7 provisions enacted, 10 in progress

Rhode Island has already…

… and is in the process of …

Connecticut – 12 provisions enacted, 4 in the works

Connecticut has already …

… and is in the process of …

New York – 16 provisions enacted

New York has already …

Washington State – 18 provisions enacted

Washington State has already …

Colorado – 13 provisions enacted, 3 in the works

Colorado has already …

… and is in the process of …

Vermont – 14 provisions enacted

Vermont has already …

… and is in the process of …

New Mexico – 10 provisions enacted, 2 in progress

New Mexico has already …

… and is in the process of …

Washington, DC – 11 provisions enacted

The District of Columbia has already …

Maryland – 11 provisions enacted

Maryland has already …

Minnesota – 11 provisions enacted

Minnesota has already …

Nevada – 10 provisions enacted, 1 in the works

Nevada has already …

… and is in the process of

And the rest of the states?

Every other state (except Mississippi) has implemented at least one or two of these provisions. You can view the entire table here. Keep in mind that this may be incomplete: I have missed a few items in some states, but there’s also new legislation being introduced, moved through the process all the time.


Charles Gaba is the founder of http://acasignups.net/, which has been live-tracking Obamacare enrollments since the exchanges launched in October 2013. His work has been cited by major publications from the Washington Post and Forbes to the New York Times as being the most reliable source available for up-to-date, accurate ACA enrollment data in the country.



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