While the Democratic Party determines where it wants to go next on health care — whether it’s Medicare for All, Medicare for America, or any one of the other 2020 health proposals — state lawmakers are shoring up the party’s signature policy, the Affordable Care Act (ACA).

So far in 2019, state legislatures in Colorado, Maine, Maryland, and New Mexico are moving bills to bolster the 2010 health law, like securing consumer protections for people with pre-existing conditions. Some of these same states are going even further by pursuing a public option.

The ACA has taken quite the beating since Donald Trump became president. By signing the GOP tax bill into law in 2017, and thus zeroing out the tax penalty for not having health insurance, the president has left the law especially vulnerable. In 2018, a Texas federal judge struck down the entire ACA on the grounds that the health law couldn’t stand without the individual mandate. (Although, legal experts think the Supreme Court will disagree with the highly partisan judge.)

The Trump administration has also bypassed Congress to undermine the ACA marketplace and Medicaid expansion. This has been done by significantly cutting open enrollment marketing and outreach, freeing up access to skimpy health plans, and allowing states to implement Medicaid work requirements. Federal officials have also hobbled other bits of the law, like rolling back the birth control mandate.


A lot of this executive action has been met with lawsuits. But state lawmakers have also rebuked the administration through legislative action, as they can’t afford to wait for folks in Washington, D.C. to address the issue. Democrats in the U.S. House of Representatives are trying to pass bills to stabilize the ACA, but the legislation’s political outlook is uncertain as Republicans still control the Senate and the White House.

“NO guarantee we’ll retake [the White House],” tweeted Charles Gaba, who tracks the ACA on his website, ACASignups.net. “STATES need to protect/strengthen ACA in the meantime.”

“The country is going to have a major conversation about the basic structure of American’s health care system. Whether it gets resolved in 2021, 2023, it’s not going to be enacted overnight. So the question is, what will we do before that important conversation is settled and implemented, because people are hurting right now,” said Stan Dorn, director of the National Center for Coverage Innovation and senior fellow, Families USA.

Some states are taking action. The Maine and New Mexico legislatures passed bills, enshrining federal protections for people with pre-existing conditions in case the Texas ruling is upheld. Maine Gov. Janet Mills (D) just signed the measure into law, and also recently rejected Medicaid work requirements pursued by her predecessor, Paul LePage (R).

What started off as Marylanders trying to solve for the lack of national individual mandate, evolved into something else: a bill that would use state tax forms to identify the uninsured and refer them to Medicaid or marketplace plans.


“It’s become a method to expedite, streamline enrollment into health coverage,” said Dorn. (Families USA helped devise the proposal.) “I’ve already heard from people in other states that there is some real interest.”

Over the weekend, the Maryland House of Delegates passed the unprecedented bill. Most states are mitigating damage done by the GOP tax bill by passing state-level mandates, as was the case in New Jersey and Vermont.

“Right now we are focused on making this bill work to see how many people we can get insured through extensive use of the tax system… other states should do the same thing,” said Maryland Health Care for All Coalition President Vincent DeMarco. DeMarco is also a part of a Maryland state panel tasked with monitoring and responding to Republican attempts to chip away at the ACA.

“The most important thing we can do is protect and build on the Affordable Care Act,” DeMarco told ThinkProgress, adding that he’d like to see a 2020 Democratic candidate committed to “protecting and building” on the ACA.

The ACA has accomplished a lot, with more than 20 million people gaining health coverage. Despite historic gains, 28.5 million still did not have health insurance in 2017.


“Tuning and fiddling is required” of every major legislation, particularly in its early years, said Dorn. But the ACA requires more tinkering because of how it was passed. For example, Republicans never wanted to engage with Democrats and pass a technical corrections bill, which is standard for something as paramount as the ACA.

That’s why states are trying to get creative.

New Mexico lawmakers are looking into a public option now that Democrats have a state government trifecta, thanks to the midterm elections. Lawmakers recently introduced a Medicaid Buy-In bill that allows any resident to enroll in the federal-state health program if they’re currently ineligible for Medicaid, Medicare, or ACA subsidies and don’t have employer-based insurance. Just north of New Mexico, lawmakers in Colorado are also working on their own public option.

Colorado lawmakers also reintroduced a bill last month that aims to drive down insurance premiums by creating a reinsurance program, which is basically insurance for insurers. The administration has approved various reinsurance programs in Alaska, Maryland, New Jersey, and Wisconsin.

Meanwhile, GOP-led states are continuing to roll back the ACA after Republicans on Capitol Hill repeatedly failed to repeal and replace President Barack Obama’s landmark health law. Kansas, where Republicans are working to allow companies to sell insurance that skirts federal law, is a good example of this, notes the Huffington Post. There, lawmakers are trying to resurrect pre-ACA insurance policies that do not include key health benefits coverage.

Amid all of this legislative action, one thing is certain: as Democrats decide whether they can even radically transform the health care system, it’s already changing for people depending on zip code.