The U.S. Senate stands poised to debate a bill, the Better Care Reconciliation Act, that would not only repeal major provisions of the Affordable Care Act, but would also fundamentally alter the state-federal framework for insurance regulation. A key provision would create federally certified small business health plans that are exempt from most state laws. In their latest article for The Commonwealth Fund, Kevin Lucia and Sabrina Corlette examine the impact of this provision on small businesses and states’ historic authority to protect consumers and manage their insurance markets.