From a proposal to a law, the Affordable Care Act, was written with the intent that the states and federal would be a partnership. However, reality has been a bit different – some states refused to stand up their own exchange and some have refused to expand Medicaid.

Effectively, a state-federal partnership is crucial to ACA, and one example that can be learned from is CHIP (Children’s Health Insurance Program). When CHIP was rolled out, state actions were extremely critical to implementation of the program.

For example, Virginia and Texas, two states that have been resistant to ACA, were resistant to CHIP as well but the process deservers a look Initial resistance by the state’s governor caused the delay in implementation of CHIP in both states. With changing governors and increased interest in the benefits of CHIP, both states saw a slow but steady implementation of CHIP. Over time a variety of factors contributed to the acceleration of the program, and the implementation started picking up. Aggressive implementation policies were adopted; effective practices were implemented; and real time problem solving was executed to provide coverage gains for children. The progress neighboring states were making in the implementation of CHIP and the subsequent rewards were key to the progress. The strict rules on federal funding forfeit were another catalyst to the progress of the program. The implementation of CHIP established new ground rules and best practices that could be used by ACA to improve the current level of state-federal partnership.

a)   The rulemaking and review process can be used to increase implementation flexibility for states. This brings in a sense of doing things their own way and transforms implementation into a mutually beneficial task.

State Exchange

b)   By capturing and showing the success stories, states contemplating implementation can be persuaded to see the benefits of the law. This uplifting can reduce the associated risk for states, highlight effective implementation policies, and can motivate states to implement the law through healthy competition.

c)   The state-federal partnership should be a supportive, collaborative endeavor where there is a sense of shared responsibility. Through open communication channels, federal government and state governments can coordinate to make implementation easier.

d)   A major boost to CHIP implementation came through philanthropic endeavors. Contributions toward technical assistance, learning and open communication between state and federal governments resulted in faster implementation. If a similar philanthropic effort were to support ACA, the gains to the program could be very rewarding.

The main take away is that just like any other implementation, CHIP took time. It was a combination of efforts from a variety of sources and was a rocky journey. We know that the ACA implementation and enrollment will be a gradual, uneven affair. .If the states and federal government partner like they did during the implementation of CHIP, the ACA can evolve and unlock its true potential.

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