In this essay, I discuss the costs and benefits to state-led changes to the Patient Protection and Affordable Care Act (ACA). I begin by offering background surrounding the creation of the ACA and the goals President Obama and Democratic lawmakers hoped it would accomplish. Then, I discuss Medicaid waivers as a primer due to the relative recentness of the ACA waivers. Following that discussion, I examine three case studies of states that have attempted to or have successfully made changes to the ACA. Based on the case studies and the frequent conservative tilt of Medicaid waivers, I find that federalist approaches to the ACA are more likely to undermine the ACA than they are to strengthen it. Although waivers were included in federal legislation as a non-partisan vehicle to allow states to be laboratories for innovation, the large role the President plays in approving or denying waivers and creating the regulations surrounding waivers puts state innovation at the mercy of whoever occupies the Oval Office
