Will Section 1332 of the Affordable Care Act  — State Innovation Waivers —  open up broad sunlit uplands of  highly creative reform or will its main effects be a race to the bottom by low-tax-obsessed states? This Commonwealth Fund report looks at the possibilities, including how eight states might make changes.

Justice Louis Brandeis called the states the “laboratories” of American democracy. We’ll see if in the case of Section 1332 they’re run by mad scientists and cynical politicians or kindly statesmen.

Section 1332  takes effect in 2017. It  will widen the ability of states to innovate by letting their officials reappraise the ACA’s coverage designs and then make changes regarding covered benefits, subsidies, insurance marketplaces,  qualified health plans and (politically very important) individual and employer mandates

But these ACA elements may not be waived, says a Commonwealth Fund analysis of the law:

      * States  must not  deny coverage or increasing premiums based on medical history.

• States must provide coverage  at least as comprehensive as coverage absent the waiver.
•  States must provide coverage and cost-sharing protections against excessive out-of-pocket spending at least as affordable as coverage without the waiver.
• States must provide coverage to at least a “comparable number of residents”  as would have been covered without the waiver.
• The waiver must not increase the federal deficit.

We wonder if the political risks for governors and state legislators in crafting more of their own health systems will send them rushing back to the Feds for the latter to take more of the responsibility again.