Rhetorical Federalism: The Role of State Resistance in Health Care Decision-Making

Abstract

The Patient Protection and Affordable Care Act (ACA) represents the most significant reform of the United States health care system in decades. ACA also substantially amplifies the federal role in health care regulation. Among other provisions, ACA expands government health care programs, imposes detailed federal standards for commercial health insurance policies, creates national requirements on employers and individuals, and enlists state administrative capacity to implement various federal reforms. In response, a persistent voice in the protracted, contentious debate surrounding ACA was, and continues to be, resistance from states. The rhetoric of federalism — states’ rights, reserved powers, state sovereignty, limited government, and local diversity — resonates deeply even around provisions of ACA that do not specifically implicate state interests. For example, the loudest and most persistent state objections target the new mandate that individuals maintain health insurance, a requirement imposed by ACA and enforced through federal tax penalties.

Pascal's Wager: Health Insurance Exchanges, Obamacare, and the Republican Dilemma

“…No sooner had the ACA passed than Republicans launched a campaign to ''repeal and replace'' the law. Opposition to ''Obamacare'' has been widespread among state Republican leaders and engendered a robust nullification movement (Leonard 2011). Twenty-six states joined a lawsuit challenging the ACA's constitutionality, Virginia pursued an independent lawsuit, and nineteen states passed legislation or adopted resolutions opposing elements of the law (NCSL 2013).…”