In the six years since the Affordable Care Act was enacted, the law has survived not one but two Supreme Court challenges, a presidential election, and more than 50 attempts by Congress to repeal the law, including one attempt that made it to the President’s desk. For health policy wonks, the continuing barbs have just become part of the regular chatter on the law now known as “Obamacare” by lovers and haters alike.

But sprinkled in the news coverage of the latest legal challenge and a GOP plan to replace the ACA is evidence that perhaps things are starting to take a turn in at least a few states that previously made news opposing Obamacare.

Four states that have been vocal opponents of the ACA have taken action recently to step back into the fray to enforce the law, protect consumers and stabilize their markets.

• Missouri: One of the early opponents of the ACA, Missouri enacted a law that made it a crime for state employees to do any work at all on implementing an ACA marketplace. Missouri is also one of the few “direct enforcement” states that early on deferred to the federal government to enforce ACA reforms. But with a law signed this month, Missouri regulators gained the authority promoted in the ACA to review proposed health insurance rates.
• Florida: Governor Rick Scott has been one of the most vocal opponents of the ACA, refusing to take federal funding to implement the ACA, establish a state marketplace, or expand Medicaid. But Florida’s Office of Insurance Regulation, as a condition of approving the proposed merger of Aetna and Humana, is requiring Aetna to offer coverage through the federally facilitated marketplace in underserved areas of the state.
• Alaska: Then-Governor Parnell was quick to point out the flaws of the ACA and refused to establish a state-run marketplace. But last month Republican leaders enacted a law intended to shore up insurers and stabilize individual market premiums through a state-run reinsurance program.
• Alabama: Governor Bentley has said the ACA is “deeply flawed and does little to help improve the health of our citizens.” But with action taken this Spring, the federal government is no longer directly enforcing federal law in Alabama – the state Department of Insurance has committed to reviewing insurance plans for compliance with the ACA and other federal health laws. It also now joins the ranks of states with an “effective rate review program.”

The ACA is not alone among major federal health laws. Slow and gradual state implementation is more the norm than the exception. For example, five years after the Health Insurance Portability and Accountability Act (HIPAA) of 1996 was enacted, the Government Accountability Office reported to Congress that states were continuing to “evolve” in their response to enforcing HIPAA protections for their residents. And although most states had established Medicaid programs within 5 years of enactment, the last state (AZ) didn’t come on board for nearly two decades. As states continue to “evolve” on ACA implementation, we’ll keep CHIRblog readers posted.