Explanation of Topics: Federal Health Reform: State Legislative Tracking Database

The Health Reform Legislative Tracking Database for 2011-2013 is intended to capture introduced state legislation for the 2011, 2012 and 2013 Legislative Sessions related to the Patient Protection and Affordable Care Act and the Health Care Education and Reconciliation Act, together referred to as the Affordable Care Act (ACA) of 2010.

Topics in Database
Updated Dec. 2013

For More Information

The explanations of topics provided below are brief highlights of filed legislation contained in the database and are not intended to include all features or provisions. Users can search text for examples and specific key words.  For information on legislative organization and procedures, click here.


Access to Primary Care

The federal law is intended to increase access to quality health care. This topic in the database captures legislation related to basic health plans, medical homes, increasing the primary care workforce and other bills that use the federal law to increase access to primary care service to individuals. .”  The Basic Health Program is an option for states under the Patient Protection and Affordable Care Act (PPACA) that allows the use of federal tax subsidy dollars that would otherwise be used for subsidies in the exchange, to be used for coverage for people with incomes between 139 percent and 200 percent of the federal poverty guidelines. The medical home relies on a team of providers—such as physicians, nurses, nutritionists, pharmacists, and social workers—to meet a patient’s health care needs. This topic was added to the database in 2013.



Many state legislatures and governors continue to set up the infrastructure to implement provisions of  the law. State implementation efforts continue to build as provisions take effect and deadlines approach. To date, some of the most common efforts include creating task forces or appointing officials responsible for moving forward with federal requirements and closely examining how to implement major provisions such as health insurance exchanges, insurance reforms, and Medicaid expansion. State legislatures have also  authorized agencies with responsibilities for implementation, including applying for funding available to states through the Affordable Care Act.


Challenging and Alternatives

In response to the Affordable Care Act, legislators in at least 40 states proposed to block, oppose or not participate in elements of the federal law through statutes, constitutional amendments and joint resolutions. Since 2009, 20 states have passed legislation that opposes elements of health reform. These include measures to prohibit state agencies or employees from implementing or enforcing requirements that individuals or employers purchase mandated insurance or face fines for non-participation. Since the U.S. Supreme Court upheld most provisions of the law, recent measures would restrict state government involvement, seek authority to join an interstate compact for multiple states opposing enforcement. A few propose alternative mechanisms that may not be compatible with the federal law.  Click here for more details on this topic.


Essential Health Benefits

A major focus for 2012-13 addresses how federally required "essential health benefits" (EHB) affect existing state laws mandating specific health benefits. Recent HHS regulations issued in 2012 and 2013 give states some options to pick an existing in-state insurance plan as a standard for policies sold beginning January 2014.  Click here for more NCSL information.  For previous years (2011 and 2012) these measures were classified under “Health Insurance Reform.”


Health Information Technology (HIT)

The Affordable Care Act builds on the health information technology development that was begun under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. Through the development of HIT systems, such as electronic health records, e-prescribing and health information exchange (HIE), the health care system will provide electronic resources for practitioners and patients. States play a pivotal role in the transition to an electronic system. As purchasers, regulators, providers and planners, states influence the pace of this transition, and become laboratories for best practices as this new industry evolves. In order to comply with requirements set forth in the ACA, states are considering legislation aimed at HIE development, privacy and security of medical information, and many other issues surrounding HIT.


Health Insurance Exchanges

Exchanges are, for most states, newly established entities that function as a marketplace for buyers of health insurance, giving them choices for health coverage. The Affordable Care Act required health insurance exchanges to be established and working by October 2014 in every state. The ACA gives states the option to establish one or more state or regional exchange(s), or partner with the federal government to run certain functions of the exchange. If a state chooses not to create an exchange, the federal government will set up the exchange(s) in the state. Seventeen states will run their exchange, seven are partnering with the federal government and the rest are having the federal government run the exchange in the state (as of winter 2014). In almost all states, there are two separate exchange operations – one for the individual market and another for the small group employer market (SHOP). This topic includes legislation to create or prohibit an exchange as well as legislation that addresses certain functions of the exchange, such as navigators, grants, interoperability, etc.  Click here for more information on State Actions to Address Health Insurance Exchanges.


Health Insurance Reform

The Affordable Care Act establishes a series of uniform, requirements and additional options for states that build on existing state regulation of health insurance policies. These include standard-price insurance coverage for individuals with pre-existing conditions, family coverage that includes dependent members up to age 26, expanded review of premium rates, required ratios of insurer expenditures on health services, consumer assistance or ombudsman offices, reduced employer shares for retirees between ages 55 to 64, and patients’ rights to appeal denied coverage. A dozen such provisions are in place for 2010-2013, including optional federal grants to states. In 2011-12 at least 45 states considered related bills. A major focus for 2012-13  is more uniform mandated "essential health benefits" based on latest HHS regulations; click here for more 2013 legislative information.  Future provisions include preventive screenings and services with no co-payments, no lifetime or annual limits on standard policies and options for multi-state or out-of-state health insurance purchasing. "Health Insurance Exchanges" are a central element of insurance reform, but are identified and listed separately -- users can obtain a single list that combines both groups of bills. Also see "Challenging and Alternatives" bills which also affect insurance policy.  Click here for more insurance reform information, including a report on enacted and signed laws specific to ACA health insurance implementation



The Affordable Care Act expanded eligibility for Medicaid, beginning January 1, 2014, providing for states to cover all Americans with family incomes up to 133 percent of the federal poverty guidelines ($23,550 for a family of four in 2013), although states now have the option to participate or not in the expansion.  This Medicaid expansion provision led to challenges that rose to the Supreme Court where, on June 28, 2012, the court ruled that Congress may not make a state’s entire existing Medicaid funds contingent upon the state’s compliance with the PPACA Medicaid expansion.  In practice, this ruling makes the Medicaid expansion a voluntary action by states. 
The Court's decision sparked many questions from state policymakers. In a series of letters, the  Department of Health and Human Services (HHS) has begun to clarify its interpretation of the ruling. Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services,  clarified in a letter that no deadlines had been set for states to make a decision concerning the expansion of their Medicaid programs.  The optional expansion is not the only PPACA-related Medicaid change state policymakers face. The law also made several changes that influence Medicaid operations and the program’s cost to states.  States have the primary responsibility to comply with new federal requirements.  States are creating policies about eligibility, coverage and enrollment options, enrollment systems, compatibility with the exchanges, among other issues.  Click here for more information.



The Affordable Care Act includes many provisions and may affect many state laws, including income taxes, small business taxes, pharmaceuticals, and much more. This topic is intended to capture legislation that does not fit into other topic areas.


Prevention and Wellness

The Affordable Care Act (ACA) created the Prevention and Public Health Fund to reduce and prevent chronic diseases, and improve health for all people. In FY2010 and FY2011, federal funding helped train new primary care providers, improve access to community health services and screenings, strengthen public health infrastructure and workforce, combat childhood obesity, prevent smoking and tobacco use, and promote healthy eating and active living. 
To respond to the provisions set forth in the Act, states have begun considering legislation to authorize responsibility to a particular agency for implementation, including applying for funding available through the ACA; providing complete coverage of clinical preventive services; permitting employers to offer incentives to employees for participating in a wellness program and meeting health related goals; and providing tax credits to employers who offer wellness programs. Click here for more information.


 Workforce and Providers  

States are moving forward with implementing provisions of the Patient Protection and Affordable Care Act (PPACA) which expand insurance coverage and delivery systems. Health care providers must be able to handle the increased need for services.  The PPACA will support existing state efforts to address health care provider shortages across several professions; increase workforce capacity in rural areas through the National Health Service Corps; and address licensure and regulatory issues related to providers.  Through the Prevention and Public Health Fund, PPACA will increase the number of primary care physicians, physician assistants’ expertise in primary care, and the number of nurse practitioners (while also establishing new nurse practitioner-led clinics). The law will also provide states with $2.75 billion in 2013 and 2014 and $2 billion annually after that starting in 2015 to increase their health care workforce from 10 percent to 25 percent over the next 10 years. The PPACA also aims to invest in graduate medical education, increasing resources for training, and providing incentives for providers who serve in underserved areas. Between 2011 and 2013 there have been 73 bills proposed in 19 different states, territories or DC, one of which was vetoed and 14 of which have been signed into law.