Vol 23, 2014 Annals of Health Law 53
THE ACA AND PEOPLE LIVING WITH HIV/AIDS
likely to continue, as federal budgetary shortages continue to put pressure
on public services and reimbursement rates continue to be cut.205
C. Accountability and Enforcement
PPACA allocates substantial enforcement authority to the states, in part
because the Public Health Service Act gives them primary enforcement
authority over insurance issuers in the group and individual markets.206
This enforcement authority includes such things as reviewing premium rate
increases and establishing the health insurance exchanges.207 As the
Medicaid access crisis illustrates however, when the states exert substantial
control over federal programs local budgetary concerns can encourage
states to arbitrarily narrow the scope of these programs and limit the
benefits available to applicants.208 Moreover, while some states look ready
to vigorously enforce many of PPACA’s provisions,209 other states have
explicitly refused to do so.210 The hostility of many states to PPACA along
with the inevitable state budgetary issues potentially means a broader than
expected enforcement role for federal agencies. In certain areas, like
reviewing premium rate increases, state to state variation is already proving
at 2 (9th Cir. Sept. 17, 2013) (challenging California’s elimination of Medicaid coverage
for adult dental, podiatry, optometry and chiropractic services); Managed Pharmacy Care v.
Sebelius, 716 F.3d 1235, 1240 (9th Cir. 2013) (challenging California’s Medicaid
reimbursement rate reductions); Pashby v. Delia, 709 F.3d 307, 313 (4th Cir. 2013)
(challenging North Carolina’s imposition of stricter eligibility requirements for in-home
personal care services through Medicaid).
205. See Robert Pear, States Can Cut Back on Medicaid Payments, Administration Says,
N. Y. TIMES Feb. 26, 2013, at A17.
206. Ctrs. for Medicare & Medicaid Servs., The Centers for Consumer Information and
Consumer Oversight: Compliance, http://www.cms.gov/CCIIO/Programs-and-Initiatives/
Health-Insurance-Market-Reforms/ compliance.html; see also Moncrieff & Lee, supra note
20, at 287 (noting that despite the fact that PPACA provides national standards
implementation of those standards primarily takes place at the state level).
207. Id. at 289.
208. See, e.g., Pashby, 709 F.3d at 313 (holding that North Carolina had limited the
availability of home personal care service in violation of the Social Security Act).
209. See Katie Keith et al., Implementing the Affordable Care Act: State Action on the
2014 Market Reforms 5 (Feb. 2013), http://www.commonwealthfund.org/~/media/Files/
210. See, e.g., Oklahoma Insurance Commissioner Refuses to Enforce Affordable Care
Act, INS. J. (Mar. 18, 2013), http://www.insurancejournal.com/news/southcentral/2013/
03/18/ 285029.htm. House Republicans have engaged in similar efforts in order to slow the
implementation of PPACA. See, e.g., Robert Pear, House Votes to Delay Two Requirements
of the Health Care Overhaul, N.Y. TIMES, July 17, 2013, at A13. Their efforts seem to be
succeeding. See Jackie Calmes & Robert Pear, Crucial Rule is Delayed a Year for Obama’s
Health Law, N. Y. TIMES, July 3, 2013, at A1.