INTRODUCTION: Securing Reproductive Justice After Dobbs.

When we conceptualized this symposium, Roe v. Wade1 was still the law of the land, albeit precariously. We aimed to commemorate its fiftieth anniversary by exploring historical, legal, medical, and related dimensions of access to abortion as well as the challenges ahead to secure reproductive justice. With the leak of the U.S. Supreme Court's decision in Dobbs v. Jackson Women's Health Organization on May 2, 2022, we shifted to mark the dawn of a new era. In the nearly identical official opinion announced on June 24, 2022,2 Justice Samuel Alito, writing for the majority (6-3), overturned Roe and Planned Parenthood of Southeastern Pennsylvania v. Casey.3.

Georgia Pathways-Partial Medicaid Expansion With Work Requirements and Premiums.

This Viewpoint discusses the Georgia Pathways to Coverage program, which is the first state program that partially expands Medicaid eligibility to low-income adults with work requirements.

Private Actions to Protect Medicaid Live to See Another Day.

This Viewpoint discusses the recently decided Supreme Court Talevski lawsuit that affirmed that private parties can enforce federal Medicaid law against noncompliant states.

Medicaid, the Supreme Court, and Safe Care for Nursing Home Residents.

This Viewpoint details the risk to Medicaid beneficiaries if the Supreme Court supports a decision that will allow states to deny benefits to eligible recipients and deny beneficiaries' ability to hold states accountable in federal court.

Medicaid Waivers, Administrative Authority, and the Shadow of Malingering.

From 2018 through 2020, HHS approved state Medicaid demonstration waivers to impose new eligibility conditions such as work requirements, connecting current "personal responsibility" rhetoric and historical suspicion of malingering. The Biden administration reversed course but advocated to the Supreme Court for expansive administrative discretion. This approach supports health equity now but could enable reemergence of restrictive health policies down the road.

Pursuing Medicaid Block Grants with the Healthy Adult Opportunity Initiative: Dressing Up Old Ideas in New Clothes.

The Trump administration's Healthy Adult Opportunity waiver follows a long history of Republican attempts to retrench the Medicaid program through block grants and to markedly reduce federal spending while providing states with substantially greater flexibility over program structure. Previous block grant proposals were promulgated during the presidential administrations of Ronald Reagan and George W. Bush and majorities in Congress led by House Speaker Newt Gingrich and House Budget Committee Chair and then Speaker Paul Ryan. Most recently, Medicaid block grants featured prominently in Republican efforts to repeal and replace the Affordable Care Act. This essay traces the history of Republican Medicaid block grant proposals, culminating in the Trump administration's Healthy Adult Opportunity initiative. It concludes that the Trump administration's attempt to convert Medicaid into a block grant program through the waiver process is illegal and, if implemented, would leave thousands of people without necessary medical care. This fact, combined with failed legislative efforts to block grant Medicaid during the last forty years, highlights the substantial roadblocks to radically restructuring a popular program that helps millions of Americans.

Struggle for the Soul of Medicaid.

Medicaid is uniquely equipped to serve low-income populations. We identify four features that form the "soul" of Medicaid, explain how the administration is testing them, and explore challenges in accountability contributing to this struggle. We highlight the work of watchdogs acting to protect Medicaid and conclude with considerations for future health reform.

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects.

Have the ACA's Exchanges Succeeded? It's Complicated.

The fight over health insurance exchanges epitomizes the rapid evolution of health reform politics in the decade since the passage of the Affordable Care Act (ACA). The ACA's drafters did not expect the exchanges to be contentious because they would expand private insurance coverage to low- and middle-income individuals who were increasingly unable to obtain employer-sponsored health insurance. Instead, exchanges became one of the primary fronts in the war over Obamacare. Have the exchanges been successful? The answer is not straightforward and requires a historical perspective through a federalism lens. What the ACA has accomplished has depended largely on whether states were invested in or resistant to implementation, as well as individual decisions by state leaders working with federal officials. Our account demonstrates that the states that have engaged with the ACA most consistently appear to have experienced greater exchange-related success. But each aspect of states' engagement with or resistance to the ACA must be counted to fully paint this picture, with significant variation among states. This variation should give pause to those considering next steps in health reform, because state variation can mean innovation and improvement but also lack of coverage, disparities, and diminished access to care.

What Is Federalism in Healthcare For?

The Affordable Care Act (ACA) offers a window into modern American federalism--and modern American nationalism--in action. The ACA's federalism is defined not by separation between state and federal, but rather by a national structure that invites state-led implementation. As it turns out, that structure was only a starting point for a remarkably dynamic and adaptive implementation process that has generated new state-federal arrangements. States move back and forth between different structural models vis-a-vis the federal government; internal state politics produce different state choices; states copy, compete, and cooperate with each other; and negotiation with federal counterparts is a near constant. These characteristics have endured through the change in presidential administration. This Article presents the results of a study that tracked the details of the ACA's federalism-related implementation from 2012 to 2017. Among the questions that motivated the project: Does the ACA actually effectuate "federalism," and what are federalism's key attributes when entwined with national statutory implementation? A federal law on the scale of the ACA presented a rare opportunity to investigate implementation from a statute's very beginning and to provide the concrete detail often wanting in federalism scholarship. The findings deconstruct assumptions about federalism made by theorists of all stripes, from formalist to modern. Federalism's commonly invoked attributes--including autonomy, cooperation, experimentation, and variation--have not been dependent on any particular architecture of either state-federal separation or entanglement, even though theorists typically call on "federalism" to produce them. Instead, these attributes have been generated in ACA implementation across virtually every kind of governance model--that is, regardless whether states expand Medicaid; get waivers; or operate their own insurance exchanges or let the federal government do it for them. This makes it extraordinarily challenging to measure which structural arrangements are most "federalist," especially because the various federalism attributes are not always present together. The study also uncovers major theoretical difficulties when it comes to healthcare: Without a clear conception of the U.S. healthcare system's goals, how can we know which structural arrangements serve it best, much less whether they are working? If healthcare federalism is a mechanism to produce particular policy outcomes, we should determine whether locating a particular facet of healthcare design in the states versus the federal government positively affects, for example, healthcare cost, access, or quality. If, instead, healthcare federalism serves structural aims regardless of policy ends--for instance, reserving power to states in the interest of sovereignty or checks and balances--we should examine whether it does in fact accomplish those goals, and we should justify why those goals outweigh the moral concerns that animate health policy. The ACA did not cause this conceptual confusion, but it retained and built on a fragmented healthcare landscape that already was riddled with structural and moral compromises. This does not mean that federalism is an empty concept or that it does not exist in the ACA. Federalism scholars tend to argue for particular structural arrangements based on prior goals and values. The ACA's architecture challenges whether any of these goals and values are unique to federalism or any particular expression of it. At the same time, the ACA's implementation is clearly a story about state leverage, intrastate democracy, and state policy autonomy within, not apart from, a national statutory scheme. Its implementation illustrates how federalism is a proxy for many ideas and challenges us to ask what we are really fighting over, or seeking, when we invoke the concept in healthcare and beyond.

The Supreme Court Ruling That Blocked Providers From Seeking Higher Medicaid Payments Also Undercut The Entire Program.

In Armstrong v. Exceptional Child Center, Inc., the US Supreme Court revisited the question of whether Medicaid providers may seek relief in federal courts when states fail to pay "sufficient" Medicaid rates. A divided Supreme Court held that the Supremacy Clause of the US Constitution does not support such actions, even when states violate the Medicaid Act of 1965. Payment sufficiency is vital to Medicaid's success in expanding health insurance coverage under the Affordable Care Act. By terminating providers' ability to seek relief in federal courts, Armstrong makes it easier for states to cut Medicaid payment rates at the same time that millions of new enrollees will enter the program, undercutting operation of the Medicaid program and its role in health care reform.

Post-reform Medicaid before the court: discordant advocacy reflects conflicting attitudes.

This essay explores the conflicting positions taken by the United States in its Medicaid-related briefs before the Supreme Court this October 2011 Term. In Douglas v. Independent Living Center, the United States articulated a deferential stance toward the states, a position consistent with longstanding states' rights concerns in the Medicaid program. On the other hand, the federal government has advocated a very broad view of federal authority under the spending power to modify and expand Medicaid in Florida v. Health and Human Services. Congress has acted in ways that are contradictory regarding Medicaid throughout the program's history, and those conflicting attitudes have been accentuated by the executive branch's dissonant litigation strategies this term. This essay posits that the Court could minimize confusion with narrow holdings in both Douglas and Florida v. HHS so as to allow Congress and HHS latitude to resolve their conflicting attitudes toward Medicaid as well as the intricacies of conditional spending.

Pharma on the hot seat.

The pharmaceutical industry has been receiving greater scrutiny lately due in large part to the many public and private legal enforcement actions taken against pharmaceutical manufacturers. These enforcement actions, along with legal developments such as the OIG Compliance Guidance for Pharmaceutical Manufacturers, the Sarbanes-Oxley Act's statutory guidelines for public corporations, the HIPAA privacy regulations, and the Medicare Modernization Act, have the potential to encourage the pharmaceutical industry to self-regulate beyond the bounds currently required by the law. After a brief overview of enforcement actions and compliance programs directed toward the pharmaceutical industry, this Article reviews a similar situation the hospital industry faced when Medicare promulgated major reimbursement modifications. The Article proposes that the pharmaceutical industry, in the face of such intense scrutiny and uncertainty, should implement more rigorous self-regulation. Without more stringent self-regulation, this intense interest in the pharmaceutical industry may result in a regulatory push that establishes unanticipated and cumbersome measures for the industry.