The Future of Health Care Reform — A View from the States on Where We Go from Here

The future of U.S. health care reform is muddier now than at any point in the past two decades. Health care was one of the most important issues for voters in the 2018 election, but there is little reason to believe that substantive national action is likely any time soon. The Trump administration is taking aggressive steps to undermine the Affordable Care Act (ACA) but is limited in what it can do on health policy absent legislation from Congress. States are poised to fill this vacuum. The risk of replicating the hyperpartisanship that has stalled Congress in recent years is real — 37 state governments will be controlled entirely by one party in 2019, and only Minnesota’s legislature will have split control.1 If the lessons of both the ACA’s passage and the repeal-and-replace debate is that the durable reform must be bipartisan, what does a solutions-oriented conversation look like at the state level, how do we get there, and what does this shift mean for the future of health care reform?

There are many examples of states claiming an increasingly large role in health policy, to some degree spurred by the Trump administration’s promise to allow greater flexibility. Kentucky, New Hampshire, and other states are introducing work requirements to their Medicaid programs. A larger number of states are moving toward Medicaid expansion than at any point since 2014, including Republican-run states such as Utah, Idaho, and Nebraska, where expansion was approved by ballot in November 2018. Maryland, Massachusetts, and others are experimenting with payment reform.