The Patient Protection and Affordable Care Act (PPACA)

Subject: Law
Pages: 6
Words: 1386
Reading time:
5 min
Study level: College


The Patient Protection and Affordable Care Act (PPACA) is one of the recent medical care policies in the United States. PPACA is also popularly referred to as Obamacare. It is one of the most comprehensive health care reforms in the USA. The policy, if enacted fully will see most average and low income earning Americans get affordable medical care. While the bill is advantageous to the poor citizens, the apparent state control of the bill brought a lot of controversies. First the bill mandates all states to enact the legislation by imposing heavy fines on states that fail to implement the law. Secondly the bill imposes that individuals earning should purchase a health insurance policy. These issues are seen by critics as abuse of federal power and are against the constitutional framework. Proponents of the bill however argue that without strict government control, over 45 million US citizens would remain without a health care system.

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Thesis statement: The federal government should allow states to develop innovative health care solutions to suit their local situations as well as preserve state flexibility and independence.

Obamacare Bill History

Medicaid expansion which is one of the key issues in the Obamacare bill was initially enacted in 1965. The programs has expanded to cover over 60 million Americans to date. In this program, the national government provides federal funding to states that in turn develop social programs to assist low income earners. Medicaid accounts 43% of the total expenditure of the federal government to individual states. The states on the other hand are allowed to introduce flexibilities but must also meet the minimum requirement by federal government. States determine the least and highest benefits, methods of delivering the health care and the amount paid to the providers. Despite the huge grants given by the federal government, Medicaid still remains the largest expense for individual states.

The Obamacare bill sought to provide adequate health care services to over 45 million Americans. The main incentives of this policy include:

  • To expand Medicaid to poor Americans
  • To compel individuals to purchase health insurance
  • To compel states to expand their Medicaid programs
  • To compel states to initiate insurance exchange programs

Tensions between the Federal Government and States

In the US, federalism is a crucial feature in the provision of health care services. Federalism is the constitutional method of dividing power, authority and responsibility between the national government and states (Ryan, 2012). In the US, the health care roles are divided among between the national government and individual states. Medicaid implementation has brought increased the federalism controversies between the states and national government. The main questions lie on who should decide the policies adopted at the state level.

In the bill, the federal government sought to compel states into accepting the legislation or face severe consequences. The federal government imposed that states adopting Obamacare would receive large benefits in form of funding while those that did not would not receive the normal funding of Medicaid. The bill also stipulated that individuals earning should be compelled to purchase health insurance. Individual states on the other hand indicated that this was a direct abuse of power and states should have the flexibility and liberty of developing their own health care solutions. Also, citizens should choose whether or not to purchase heath care insurance.

The government justification for strict control was based on the fact that, absence of strict federal laws, mandated to all the states would mean uneven medical coverage and more so to the poor American citizens. This resulted to tensions between the federal government and local states as well as individuals.

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Negative Impacts of Federal Regulations of Obamacare (Cons)

First and foremost, for the policy to be effective, the commitment of the federal government and the respective states is necessary. Both the national government and individual states should participate in the formulation and implementation of these programs. As such, the national government should formulate policies with significant flexibilities so as to allow states to develop innovative solutions around a particular policy.

By vesting a lot of power on the federal government, local states will have no option but to follow policies developed by the government. This would reduce the powers and responsibilities of the state government. This creates a constitutional crisis on the function and limits of the federal and state governments. Thus, individual states should be allowed to develop and regulate their health insurance policies (Gais, 2010).

If the central government limits the state government roles, they would merely be implementers of the government policies. This would transform their roles from governance to administrators. That is, state governments would only implement what the government proposes.

In the court ruling on constrains imposed on Obamacare policy which sought to withdraw the current Medicaid funding for states that did not comply with the new legislation, the court argued that this was a direct abuse of federal power (Landers,2012). Thus, from a legal perspective, the federal government overstepped its mandate.

Another controversial aspect is the refusal by some states to implement insurance exchange programs as stipulated in the bill. The federal government hinted that it would step in and develop these exchange schemes for the state. If this happens, the federal government would have excised greater power and control over individual. This is against the constitutional framework of the US.

The issues of increase in federal power can also be seen in the light of few individuals wanting to shape American government. Strict control would mean that those in power would impose policies to improve their performance at the expense of the state and its citizens.

Whereas the federal government is the policy maker, individual states oversee the implementation of these policies. Forcing states to make decisions based on incentives and penalties is against the constitutional framework of the country.

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Another controversial issue is the compulsory health insurance imposed by the bill. The bill mandates that individuals earning above 138% of the federal poverty level must purchase a health insurance policy. Individuals should be given the liberty of choosing whether to purchase the policy or not.

Different states in the US have varying demographic, financials and political issues and hence one policy for all the states is impractical. Imposing a single policy on these states is difficult and impractical. The states should therefore be given the mandate to innovate and develop solutions that best suits their medical needs.

Positive impacts of federalism in the bill (Pros)

The main argument for strict federal government control lies in provision of health insurance to over 40 million poor Americans. Absence of strict federal control would leave poor individuals without adequate health care. However, if the government imposes strict control, most states and individuals will have to comply. Whereas the government guarantees health care for poor Americans in the Medicare expansion programs, the liberty of individuals and states should not be compromised. The right to liberty should be guaranteed and the government should not interfere with it irrespective of the gains to be achieved (Jacobs & Skocpol, 2011). Thus this policy is not consistent with the rule of law and the US constitutional framework.

From the policy supporter’s view, a small increase in federal power for the sake of improving health does not go against the constitution. However, abusing power should not be condoned either for the right and wrong reasons.


In conclusion, this paper evaluated the Patient Protection and Affordable Care Act (PPACA) bill in terms of federalism and the US constitutional framework. The implementation of the bill resulted to huge controversy as it mandated individuals to adopt health insurance and states to expand Medicaid and insurance exchange programs. From the legal perspective, mandating states to expand their Medicaid or individuals to buy health insurance is against the constitutional framework and an excessive use of federal power. Though the central government has power to develop policies, it cannot impose them on individuals and states as this would compromise on their liberty. States and individuals should be free to choose. The federal government should essentially develop policy and provide incentives to encourage the adoption of the new policy. There should be an element of flexibility in the policy allowing states to modernize and manage their health care problems. The government should also not mandate individuals to purchase health insurance policies.


Gais, L.T. (2010). Federalism During the Obama Administration. Web.

Jacobs, R., & Skocpol, T. (2011). Health Care Reform and American Politics: What Everyone Needs to Know. New York: Oxford University Press.

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Landers, R. (2012). The Denouement of the Supreme Court’s ACA Drama. New England Journal of Medicine, 367( 3),198-199.

Ryan, E. (2012). Obamacare and Federalism’s Tug of War Within. Web.