After the Rollback: How States Can Fight for Health Justice from Below
How state governments—and grassroots coalitions—can protect healthcare when Washington walks away
If the budget clears the House in its current form, the protections will be gone. And millions will face the quiet panic of figuring out what happens when care disappears from the federal ledger.
The rollback came dressed in the language of fiscal discipline. But for those who depend on Medicaid, ACA subsidies, or the basic assurance that their preexisting condition won’t be used as a financial weapon, the consequences are immediate—and intimate.
I’m 80 years old, and the loss of medical coverage would be life-threatening. I’ve lived long enough to know that health isn’t just a personal matter. It’s structural. It’s political. And when Washington retreats, the burden shifts—not evenly, but predictably—to those already stretched thin. I’ve seen this coming, so I’ve been thinking about what options there are not just for myself but for everyone.
The good news is the story doesn’t end in D.C.
Across the country, state governments are facing a choice: whether to absorb the damage or reinforce it. Whether to treat healthcare as a shared responsibility or let it unravel, one eligibility rule at a time.
Some states are already preparing their answer.
California, for example, didn’t wait for Congress. It codified key ACA protections in state law, extended Medi-Cal to undocumented residents, and created its own subsidy program to buffer federal cuts. Washington State rolled out a public option. Colorado capped premiums on a state-sponsored plan. New York, Massachusetts, Oregon—each has built up legal and institutional defenses against the collapse of national health policy.
But these are exceptions, not the rule.
In much of the country, including Arizona where I live, the path is narrower. The governor may support protections, but the legislature holds the purse. Efforts to build public alternatives stall in committee. Insurance companies have more voice than patients. And ERISA still blocks state regulation of large employer plans, no matter how aggressively states try to act.
Still, there is room to move—if we shift the frame.
This isn’t just about policy. It’s about the systems that organize risk, distribute vulnerability, and determine who gets to survive a health crisis with dignity—and who doesn’t. If the federal government abdicates that responsibility, the vacuum doesn’t stay empty. It gets filled by patchwork systems, fragmented care, and deepening inequity.
That’s why the states matter now more than ever.
States can regulate insurance plans in their markets. They can ban junk plans, require coverage for preexisting conditions, mandate essential benefits, and cap out-of-pocket costs. They can expand Medicaid using their own funds, build reinsurance programs to stabilize premiums, and create public options designed to serve—not skim—the marketplace.
Yes, it takes money. And yes, it takes political will. But not every fight has to wait for federal permission. Minnesota didn’t. It’s using its existing public program—MinnesotaCare—as a platform for a state-based alternative to private insurance. New Mexico is using a surtax on health insurance premiums to fund expanded coverage. Even Maine is exploring how to use state funds to shield residents from the worst fallout of federal retreat.
These aren’t theoretical fixes. They’re happening now. And they expose a deeper truth: while health is often framed as a federal issue, the power to protect people has always been layered, distributed, and contested.
The question is whether we organize around that power—or surrender it.
In anthropology, we often study how systems break. But we also study how people adapt. In moments of crisis, informal networks, mutual aid, and local institutions often step in where the formal state has failed. In the U.S., we have formal state governments with the capacity—if not always the will—to act. That makes this a question not of possibility, but of politics.
So here’s what we should be asking now, in every statehouse: Will you protect people with cancer, asthma, or diabetes from being priced out of care? Will you fund public alternatives where private markets fail? Will you treat health as a right—or as a risk to be privatized?
And if the answer is no, we should be equally prepared to act from below: through coalitions, county health boards, city programs, labor unions, and public health alliances that treat care as a form of solidarity, not just service.
The federal rollback was designed to create a vacuum. Let’s not leave it empty.
Suggested Readings
Bambra, Clare. Health Divides: Where You Live Can Kill You. Bristol: Policy Press, 2016.
Brown, Wendy. Undoing the Demos: Neoliberalism’s Stealth Revolution. New York: Zone Books, 2015.
Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press, 2003.
Geronimus, Arline T. Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society. New York: Little, Brown Spark, 2023.
Sparke, Matthew, and Shanti Vilas. Neoliberal Disease: How US Politics Sabotaged Public Health and Fueled COVID-19. Oakland: University of California Press, 2022.
Vélez-Ibáñez, Carlos G., and James B. Greenberg. “Formation and Transformation of Funds of Knowledge Among U.S. Mexican Households.” In Reflections of a Transborder Anthropologist, edited by Carlos G. Vélez-Ibáñez, 177–197. Tucson: University of Arizona Press, 2020.
Weaver, Thomas, James B. Greenberg, Anne Browning, and William Alexander, eds. Neoliberalism and Commodity Production in Mexico. Boulder: University Press of Colorado, 2012.
KFF (Kaiser Family Foundation). “How State Policies Shape Access to Health Coverage.” San Francisco: KFF, 2024.
Well said.
This also true for clean energy and climate change, which has been my field for 50 years. During the 1980s, states invented Integrated Resource Planning to force utilities to consider energy efficiency and renewables. In the 90s, they made utilities spend billions on efficiency programs. When deregulation took the wind out of those efforts, they created renewable and efficiency standards requiring utilities to acquire clean resources. In the last 20 years, some half of the states have enacted climate action plans. These latest federal rollbacks, which happened also under Reagan and Bush II, are just the latest impetus for states (and also local governments) to step up.
James, I live in Florida and at age 72 am on SocSec and Medicare. If/when those are cut… it’s hopeless