Document Type
Article
Publication Date
2026
ISSN
0006-8047
Publisher
Boston University School of Law
Language
en-US
Abstract
The budget reconciliation bill signed on July 4, 2025 (“HR1”) weakened the Patient Protection and Affordable Care Act (ACA) and its core goal of near-universal health insurance coverage. To maintain 2017 tax cuts, Congress curtailed the ACA’s Medicaid eligibility expansion; simultaneously, HR1 limited the kinds of options states have been able to exercise within Medicaid while pushing the costs of deep cuts down to states. This essay argues that HR1 embodies an anti-federalism approach, and that anti-federalism is not the same as federalizing health reforms. In the past, Congress sometimes federalized health care or public health reforms to respond to state and/or market failures; however, this programmatic contraction neither responds to state/market failures nor to the demands of the polity. It does, however, resurface the historical exclusion of the so-called “undeserving poor.”
The essay first identifies the ACA’s substantive and structural choices for achieving universal health insurance coverage, explaining that anti-ACA arguments often complained about federal “takeover,” but the ACA actually relied on cooperative federalism structures that were part of existing health laws. In contrast, Part II shows that HR1 constrains state options in order to limit federally-supported health insurance coverage and undermine the ACA, briefly exploring the statutory provisions targeting Medicaid through new regulatory burdens placed on expansion states and populations. Part III contextualizes and analyzes these structural and theoretical changes and their implications.
Recommended Citation
Nicole Huberfeld,
The Anti-Federalism of HR1
,
Boston University Law Review
(2026).
Available at:
https://scholarship.law.bu.edu/faculty_scholarship/4313
