State Innovation Waivers: Redrawing the Boundaries of the ACA

In the federalist spirit of the rest of the Affordable Care Act (ACA), section 1332 of the law authorizes new optional waivers for state innovation. These waivers, 1332 waivers, as they have become known, offer states the flexibility to refashion their coverage systems, provided that their reforms stay within important boundaries set by statute. A year and a half out from the earliest effective date--January 1, 2017--some states have already begun the planning and engagement process required as part of the waiver application. This article discusses possible waiver strategies aimed at exchange sustainability, coverage expansion, delivery system reform, and more. States have the option to make small, targeted fixes or bring more sweeping changes to their health landscapes. Though the application process is involved and states must still accomplish the aims of the ACA, 1332 waivers give them the opportunity to tailor the law to local politics, markets, and health systems.