What significant impact did the Affordable Care Act have on federalism?

The Affordable Care Act (ACA) significantly altered the dynamics of federalism in the United States by expanding federal influence over state-level health care initiatives. One of the key provisions of the ACA required states to establish health insurance exchanges, which aimed at increasing access to health insurance for their residents. This requirement exemplified a shift where the federal government not only set the framework for health care reform but also anticipated states to play an integral role in implementing these reforms.

While states retained some authority in how to operate these exchanges, the federal government provided guidelines and options for states, thereby increasing federal oversight and influence. This arrangement illustrated a notable interaction between state and federal powers, illustrating a form of cooperative federalism where both levels of government are involved in the delivery of health care services. Thus, the ACA enhanced the federal government's role in health care policy while still engaging states in the execution of these policies.