News Release

Interplay between states and federal government in implementing the ACA

Health care reformers differ on how to provide affordable universal coverage for all

Peer-Reviewed Publication

Columbia University's Mailman School of Public Health

March 3, 2020 --The fierce national debate over health care reform includes deep divisions over the appropriate roles of the federal and state governments. For example, while Sen Bernie Sanders (I-VT) calls for expanding the federal Medicare program to cover all Americans, the Trump administration pushes for the states to have far greater authority. However, according to Michael Sparer, JD, PhD, chair of health policy and management at the Columbia Mailman School of Public Health, the Affordable Care Act (ACA) points towards a more effective inter-governmental partnership, one in which the states have significant policy and administrative discretion, bounded by strong national standards designed to limit unacceptable inequities.

In a policy paper titled "Federalism And The ACA: Lessons For The 2020 Health Policy Debate" in a special issue of the journal Health Affairs, Professor Sparer writes: "States are too prominent and too engaged in every aspect of the nation's health care system not to insist on playing an important ongoing role." Proposals to eliminate a significant state role are both unlikely to be enacted and at odds with 250 years of American history. But he adds that future reforms also need strong national standards to guarantee the desired policy outcome (such as universal coverage) and to limit unacceptable inter-state inequities

The ACA offers several models for combining centralized and state-based approaches for policy makers to develop the next generation of health reform, notes Sparer, and each of them could achieve universal coverage without eliminating the private insurance system. Indeed, rather than abandoning the ACA, reformers ought to recognize that the law suggests "the sort of intergovernmental partnership that just might lead to a US version of affordable universal coverage.

On March 10th Professor Sparer will take part in a briefing in Washington hosted by the journal. Here is more information. Registration is free.


Columbia University Mailman School of Public Health

Founded in 1922, the Columbia University Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Columbia Mailman School is the seventh largest recipient of NIH grants among schools of public health. Its nearly 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change and health, and public health preparedness. It is a leader in public health education with more than 1,300 graduate students from 55 nations pursuing a variety of master's and doctoral degree programs. The Columbia Mailman School is also home to numerous world-renowned research centers, including ICAP and the Center for Infection and Immunity. For more information, please visit

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