Both the Obama administration and critics of the controversial Patient Protection and Affordable Care Act have repeatedly stressed the importance of state flexibility in implementing various improvements to healthcare financing and access. But many healthcare leaders prefer the opposite approach.

Pluralities of participants in the most recent Commonwealth Fund/Modern Healthcare Opinion Leaders Survey urged a stronger federal role and less state flexibility as regulators continue issuing the myriad rules required to implement the 2010 federal law. And outright majorities of respondents supported a more robust federal role than even the law allowed in determining changes in “provider payment methods” and “health insurance market rules.”

“In general, no one thinks it ought to be all federal or all state; they're fairly comfortable with the balance with some wanting a little more role for the federal government,” Karen Davis, president of the Commonwealth Fund, said about the survey's major finding.

Overall, 29% of the survey respondents said the 2010 healthcare law struck a good balance between federal and state governments, while 41% said the federal government should have more authority than it allowed and 25% wanted the states to have more authority.

The significance of the findings regarding preferences for a larger federal role were less clear to others, including Dr. Joel Brill, chief medical officer at Predictive Health in Phoenix. The dominance of academic and research professionals (56% of respondents) in the survey may have skewed the results more toward a strong government role in healthcare than many who provide healthcare would support.

“They might be able to look at things from a theoretical standpoint but not a practical standpoint,” Brill said about academics and researchers. Dr. Bruce Landes, president and CEO of Southwest Physician Associates and a critic of the 2010 healthcare law, rejected the survey's limitation of choices only to increasing either federal or state government roles in healthcare.

“(T)here is no way to respond to express the opinion that most of this power should not be in the hands of government at all,” Landes wrote in an e-mail response.

Harris Interactive conducted the survey, which focused on views of the Affordable Care Act, between April 6 and May 3. A total of 203 opinion leaders from the healthcare delivery, finance and policy fields participated in the survey, the 25th in a series designed to gather opinions from healthcare leaders on policy issues.

The survey results came as the healthcare law continued a complex, multiyear implementation and national legislative and legal battles raged over whether to maintain, expand or scrap it.

Davis: New rule could stem from slow pace to adopt policies.

President Barack Obama has repeatedly sought to defuse criticism of the new healthcare law by emphasizing the various ways it allows state flexibility. For example, in February he announced his support for legislation to advance by three years a provision of the law that permits states to opt out of certain key requirements if they can find their own ways to accomplish the law's goals.

“If your state can create a plan that covers as many people as affordably and comprehensively as the Affordable Care Act does without increasing the deficit, you can implement that plan and we'll work with you to do it,” Obama said in a Feb. 28 White House address.

Such an approach drew support from 49% of the recent survey respondents.

The need for state flexibility in designing individual approaches to healthcare coverage also was and continues as a core reason for Republican criticism of the 2010 federal health law. Republicans have consistently argued that the law wrongly reduced or eliminated the ability of states to use individual approaches to cover their citizens in affordable ways, and that argument was repeatedly raised in recent months during multiple votes to overturn various aspects or the entirety of the law.

But such criticisms of the law are in marked contrast to the respondents to the healthcare leaders survey, who generally favored less state individuality even than allowed by the federal healthcare law.

For example, 50% of respondents replied that the federal government should have more authority in determining changes in “provider payment methods” and “health insurance market rules.” In comparison, 21% and 27% of respondents, respectively, thought states should have more authority in those areas.

“They are looking to the federal government, particularly the Center for Medicare and Medicaid Innovation, to really test out more innovative ways of provider payment,” Davis said about respondents who prefer more federal action.

That confidence could stem from the view of healthcare leaders on Medicare's previous provider payment reform efforts, such as the development of the DRG prospective payment system for hospitals and the resource-based relative value scale for physicians.

The majority support for a greater federal role in developing a health insurance market rule is a break from past practices, in which market regulation was state based, and it was somewhat surprising to Davis.

Such responses could stem from the slow pace of most states to adopt policies sought by some healthcare leaders, Davis said, such as guaranteed issue and community ratings.

“You could interpret that as dissatisfaction with the ways states have exercised that authority or maybe recognition that it is very hard for states to do that on their own, unless all states are doing it,” Davis said.

One specific expansion in federal authority beyond the 2010 healthcare law supported by most respondents (62%) was the creation of a federal health insurance exchange in addition to the law's state-based insurance exchanges.

Support for such a federal exchange—even if every state has its own insurance exchange—may reflect a need healthcare leaders see for options that fit multistate firms and families living in multiple states.

“Or maybe it's a recognition that some states aren't stepping up to the plate moving forward with this and we really need to think more seriously about a federal health insurance exchange to make sure that everybody has this option,” Davis said.

Although more than a year has passed since the law's enactment, many large and possibly growing obstacles at the state level to its implementation remain, according to the respondents:

89% are concerned or very concerned about the impact of the fiscal situation or budgetary pressures in states.

78% are concerned about state political resistance and pending legal challenges to the law.

71% are concerned about the technical knowledge and capacity of state agencies to implement provisions of the law.

69% are concerned about the impact of staffing levels at state agencies.

67% are concerned about the organization and performance of the healthcare delivery systems in states.

At least some of those concerns may stem from continuing uncertainty over the many regulations that the federal government—primarily HHS—still plans to promulgate in the coming years, said Michael Hagan, an economist and project officer on grants and contracts at the Agency for Healthcare Research and Quality.

“There's a lot of difference between legislation and how things are put into regulation and policy,” he said. “A lot of these opinions will depend on both how it shapes up from a federal policy perspective and how the states respond to it.”

Landes agreed the coming regulations will determine the long-term perspectives on the law.

“Having actually read the ACA, I doubt that many of the responders have read it, and if they did are probably not aware that it is not the law that counts, it is the regulations,” Landes said. “And, for most of this law, the regulations have not been written.”

Despite the general wariness among healthcare leaders with states taking a leading role in changes to the health system, survey respondents overwhelmingly supported (82%) states that are implementing provisions of the federal law early.

Several states have moved to expand their Medicaid programs and launch subsidized health insurance exchanges before the deadlines included in the federal law. Only 8% of survey respondents opposed such moves.