This presentation uses analysis of the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA), Massachusetts Health Care Reform to provide insight into how to most effectively implement the Affordable Care Act. Federal state relations are analyzed as programs are: developed in the legislative branch, rules are promulgated in the executive branch and implemented at the state level. Success and failure of these three programs can be traced in large part to a balance between state flexibility and national accountability to meet program goals.

Achieving that balance is not easy, but lessons learned from previous successes—and failures—in structuring intergovernmental relations offer unique insights into national health reform and contemporary public policy. A number of critical themes emerge from the data including the importance of existing administrative capacity and expertise, organizational routines, reporting requirements, resources, incentives and political will. For example, with the ACA findings predict very different strategies and possibilities for early success for the Medicaid expansion and the development of health care exchanges.  Medicaid, while enormously complex, is a preexisting program and expansion is funded with significant new federal money. There are strong incentives, reporting requirements and oversight. In contrast, health exchanges entail new federal insurance requirements in an area traditionally regulated by the states. Here there is less federal expertise, limited resources for implementation, considerable opposition at the state level and fewer incentives for the states to engage.

Applying insight from past policy will help understand potential differences and suggest options for increasing opportunities for successful implementation. Evidence comes from the forthcoming book, American Federalism in Practice: The Formulation and Implementation of Contemporary Health Policy, Michael Doonan, Brookings Institution Press: June 2013.