With state legislatures working their way through their 2014 sessions, attention in a number of states is focused on the actions states can take to further implementation of the Affordable Care Act (ACA). Although the name “Obamacare” focuses attention on the President, his administration, and the federal bureaucracy, state actions will also be determinants of the success of the ACA. In particular, poor adults in more than half the states, including parents and parents-to-be, will remain uninsured - as will many children who would have enrolled in Medicaid when their parents did - unless and until those states implement the Medicaid expansion. In addition, the failure, to date, of the majority of states to develop their own marketplaces has shifted more of the burden onto the federal marketplace. Even in states with a federally facilitated marketplace, states have important roles to play in regulating insurance companies and enrolling people found eligible for Medicaid and the Children’s Health Insurance Program (CHIP) in those state-run programs.

State actions over a number of years were also critical to implementation of the very successful and popular Children’s Health Insurance Program (CHIP). The research that I am doing for First Focus is identifying lessons for ACA implementation learned from implementation of CHIP. The just released brief based on my research, Successfully Navigating the CHIP State-Federal Relationship and Challenges to State Implementation, explores the potential for states initially lagging on ACA implementation to recover lost ground as political resistance abates.

The analysis focuses on CHIP implementation in Virginia and Texas, two states currently lagging in ACA implementation. In both cases, initial resistance by the states’ governors also delayed effective CHIP implementation. But in Virginia, the election of a new governor cleared the way for slow but steady progress covering uninsured children. And in Texas, initial resistance was overcome by a confluence of factors, including the presidential aspirations of then-Governor George W. Bush. In both states, persistent grassroots and policy advocacy along with gains in covering uninsured children in neighboring states helped motivate change, and the prospect of forfeiting federal funding created a sense of urgency. When priorities changed in Texas, officials were able to compensate for the late start by adopting an aggressive set of implementation policies, practices, and real time problem solving leading to rapid coverage gains for children.

The CHIP experience also indicates that federal agency policies and practices can help reduce state resistance to implementation. For example,

• Using the rulemaking and review process to boost implementation flexibility for states can make it easier for states to do things “their way” and see implementation as a win;
• Uplifting implementation success stories can make it less risky for hesitant states to move ahead, highlight effective program implementation practices, and even encourage friendly competition among states to effectively implement the new initiative; and
• Cultivating open lines of communication with state governments and among states can create a supportive community and shared sense of ownership making implementation easier.

Philanthropy also played an important role in supporting CHIP implementation by investing in technical assistance and learning opportunities for implementers, facilitating communication between and among state and federal officials, and supporting state-based advocacy. Similar philanthropic investments today in support of ACA implementation could also yield large returns.

Although now regarded as a great success, CHIP implementation and enrollment took time and was uneven, varying across states and over time. The ACA is a more ambitious, complex, and politically contentious piece of legislation, so if the CHIP experience is a reliable guide, ACA implementation will be gradual and vary by state and overtime. But if the ACA is able to demonstrate success in a number of states, it will make it more difficult for other states to resist getting on board.

Gene Lewit is Consulting Professor of Health Research and Policy at Stanford University and affiliated with Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research.