Document Type


Publication Date

Spring 2011


The Affordable Care Act1 (ACA) promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs requires thoughtful regulatory coordination between public and private health systems.

The anticipated increase in coverage is roughly split between expansions in Medicaid and private enrollment, each of which is projected to cover approximately 16 million Americans.2 How ACA will be implemented has been the subject of constant attention since its enactment, and federal regulators have been generating program and regulatory information with commendable assiduity. However, state-level reform will be crucial to the effectiveness of the ACA implementation for low-income and chronically ill people. Federal structural regulations will be implemented and interpreted at the state level. As learned from the varied implementation of Medicaid and other state/ federal programs, state efforts can either effectuate or frustrate the intent of health coverage measures. This article is focused on five key implementation issues states face as they turn to new tasks in the governance of Medicaid and private non-group and small group coverage. The Medicaid reforms and the extension of private coverage through Exchanges raise separate challenges. However, as described here, many key implementation issues apply to both systems.