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Virginia Takes Steps to Undo Health Reform

Partner Institute: 
Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory University
Survey no: 
(15) 2010
Elena Conis
Health Policy Issues: 
Political Context
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no


In March, Virginia governor Bob McDonnell signed four bills into law (three of them identical), the text of which defended the state's citizens' right to opt out of the health insurance mandate that became federal law earlier this year. The laws were part of an organized move by conservatives to challenge the constitutionality of the federal health reform recently signed into law by President Barack Obama. The controversial law takes effect in July of this year.

Purpose of health policy or idea

Early this year, Virginia state senators considered three separate but identical bills (SB 283, SB 311 and SB 417) that targeted the provision of federal health reform legislation that will require all Americans to carry health insurance. Senate bill 283, introduced by Republic Senator Frederick Quayle, states that no resident of the state of Virginia "regardless of whether he has or is eligible for health insurance coverage under any policy or program provided by or through his employer, or a plan sponsored by the Commonwealth or the federal government, shall be required to obtain or maintain a policy of individual insurance coverage." The bill also outlaws the levying of fines or penalties on any individual who chooses not to obtain health insurance. The bill specifically does not apply to students who are required by their colleges or universities to carry health insurance in order enroll in classes.

Though Democrats hold a majority in the state senate, the bills passed with the backing of some senate democrats; the state's assembly approved SB 283 with a 80-17 majority and the widespread support of many democrats. SB283, in addition to SB 311 and SB 417, were signed into law by the state's new Republican governor in early March. Similar legislation was introduced by Republicans in the state's General Assembly and also passed both houses. All four bills were signed into law by Virginia Governor Bob McDonnell in a largely symbolic ceremony, since the bills were identical. The resulting law is the first of its kind in the nation to be implemented. 

Sponsors of the three identical senate bills contend that the federal insurance mandate violates the U.S. constitution by denying citizens the right to make their own health care choices, and that it violates states' rights to legislate health care. The bills take particular aim at the provision of federal legislation that requires nearly every American to carry health insurance, and not the other provisions of the new federal law. (In addition to the insurance mandate, the federal law requires medium to large employers to provide their employees with coverage or pay penalties; it provides subsidies to enable low-income individual to purchase insurance; and it places regulations on the health insurance industry that ban denial of benefits based on pre-existing conditions and place caps on premium increases.)

Main points

Main objectives

The Virginia law's main objective is to overrule the new federal mandate requiring nearly all Americans to carry health insurance and reassert state's rights to regulate health care.

Type of incentives

There are no incentives included in the bill.

Groups affected

Residents of Virginia

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual controversial highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent system-dependent system-neutral

The debate over health reform in the U.S. has been highly polarizing, and federal level reform was not consensual. The Virginia law was supported by many Virginia democrats, several of whom signaled that they were voting in response to their constituents' wishes. In fact, American opinion has been split on health reform, and laws such as Virginia's have received much publicity and strong support from the right. As one of several laws that attempted to undo federal health reform, Virginia's law also received widespread national media coverage as well; it was thus highly visible at both the local and national levels.

Political and economic background

Virginia's political allegiances have swung back to the right in the last year. Though the state did vote for President Barack Obama in the 2008 election, Obama was the first democratic candidate to carry Virginia in over 40 years. In the gubernatorial election held last fall, the state ousted Democrat Tim Kaine and elected Republican Bob McDonnell, whose opposition to federal health reform was clear in the campaign; during the campaign, McDonnell proposed state-level health reforms that would encourage the use of health savings accounts and cut costs by reigning in Medicaid spending and promoting wellness programs based in workplaces.

McDonnell carried several districts whose Democratic representatives backed federal health reform last fall. During the House votes on health reform, two of Virginia's six Democratic representatives voted against reform, as did the state's five Republican representatives. The state has traditionally defended the protection of state rights in the face of expansion of federal law; in the debate over SB 283 and the related bills, some Democrats equated Virginia's resistance to federal health reform to the state's resistance to racial desegregation several decades ago.  

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no no no

Origins of health policy idea

According to the National Conference of State Legislatures (NCSL), "at least 39 state legislatures have proposed legislation to limit, alter or oppose selected state or federal actions, including single-payer provisions and mandates that would require purchase of insurance." In some states, legislators have proposed new laws; in others, legislators have proposed amendments to state constitutions that would in effect preserve individual freedom to choose health care.  

The proposed state laws take a variety of approaches to undoing the federal mandate. Colorado's proposed resolution would have preserved the state's ability to opt out of federally imposed requirements, but the law did not pass. An Arizona bill that passed both houses of the state's legislature last year stated that "no law or rule shall compel any person or employer to participate in any health care system." A Georgia bill that did not pass would have amended that state's constitution such that no law would be able to force any individual or employer to participate in any health care system. According to the NCSL, in 2010 only Idaho, Utah and Virginia have successfully approved measures that have or would place limits on the provisions of federal health reform law, including the individual mandate provision. Idaho's "Health Freedom Act" preserves the rights of individuals within the state to choose or decline health care; Utah's law requires the state legislature to consider and pass legislation authorizing the state's participation in federal health reform.

In 2008, the American Legislative Exchange Council (ALEC), a conservative advocacy group that promotes the causes of "limited government, free markets, and federalism," drafted model legislation to outlaw any federal requirement forcing individuals to purchase health insurance or pay a fine. In 2009, the Council promoted the legislation, encouraging lawmakers in nearly a dozen states to introduce measures based on the model by September of that year. As of March of this year, according to the Council, 36 states have filed or plan to file legislation based on the model act. Arizona has succeeded in placing a proposition closely based on the act on its 2010 ballot, which, if passed, would prevent any law from imposing "any penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan."

Though the introduction of measures based on the ALEC act was hastened in response to the advancement of health reform legislation under the Obama administration, the move to introduce laws, amendments and ballot measures aiming to preserve what supporters refer to as freedom of choice in health care actually date to 2006. That year,  Massachusetts succeeded in enacting an individual health insurance mandate, prompting lobbyists and legislators in other states to take proactive steps to prevent similar measures from passing in their own states.

Initiators of idea/main actors

  • Government
  • Providers
  • Patients, Consumers

Approach of idea

The approach of the idea is described as:
renewed: The idea behind the Virginia law was first proposed in response to the 2006 Massachusetts insurance mandate.

Stakeholder positions

Republican lawmakers argue that the federal law (which was not yet law when Virginia's senate passed SB 283) would be an unconstitutional infringement on individual rights and an undue extension of federal power into a realm that should be the domain of states. Other republican supporters of the Virginia bills argued that overruling the insurance mandate was necessary to curb health care costs and to protect the state's citizens. "This would be the first time that the federal government has said you must purchase a product by virtue of being a citizen of this nation and if you failed to do so you will penalized," Republic senator and bill sponsor Stephen Martin told the Norfolk Virginian-Pilot. Several, but by far not all, democratic lawmakers in the state disagreed. Democratic state senator Creigh Deeds argued that the bill was largely symbolic, meant only to "send a message to Congress"-but that that message would have little effect, and do little for the people of the state of Virginia.

The debate over the Virginia laws was largely a high-level, political one. Patients and consumers in Virginia appear to be split in their opinions on both national reform as well as the local challenge laws. Support from providers is also somewhat divided, with the Medical Society of Virginia adopting a partially supportive stance toward national reform, and did not directly support a local undoing of the federal reforms.  

Actors and positions

Description of actors and their positions
Gov. Bob McDonnell (Rep.)very supportivevery supportive strongly opposed
Sen. Frederick Quayle (Rep.)very supportivevery supportive strongly opposed
Sen. Stephen Martin (Rep.)very supportivevery supportive strongly opposed
Democratic Party of Virgniavery supportivestrongly opposed strongly opposed
Attorney General Ken Cuccinelli (Rep.)very supportivevery supportive strongly opposed
Medical Society of Virginiavery supportiveneutral strongly opposed
Patients, Consumers
Patients and consumersvery supportiveneutral strongly opposed

Influences in policy making and legislation

Some observers have argued that conservative lawmakers are introducing bills such as Virginia's to mobilize and organize the right. Harnessing widespread support for opposition to the current administration has been seen as key to winning added Congressional seats for Republicans in the fall 2010 elections. SB 283 and similar bills have been promoted by conservative advocates such as the ALEC, in addition to the individual lawmakers who introduced, supported and advanced such legislation in Virginia and elsewhere, including those listed under Main Actors, above.

Legislative outcome


Actors and influence

Description of actors and their influence

Gov. Bob McDonnell (Rep.)very strongvery strong none
Sen. Frederick Quayle (Rep.)very strongstrong none
Sen. Stephen Martin (Rep.)very strongstrong none
Democratic Party of Virgniavery strongweak none
Attorney General Ken Cuccinelli (Rep.)very strongvery strong none
Medical Society of Virginiavery strongweak none
Patients, Consumers
Patients and consumersvery strongweak none
Sen. Frederick Quayle (Rep.), Sen. Stephen Martin (Rep.)Gov. Bob McDonnell (Rep.), Attorney General Ken Cuccinelli (Rep.)Medical Society of Virginia, Patients and consumersDemocratic Party of Virgnia

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The Virginia law is slated to take effect on July 1, 2010. As described below (see Expected Outcome), it is unclear whether Virginia's bill will be effective in shielding the state's residents from the new federal requirement to carry health insurance, as high courts generally uphold federal law over state law. In February, Virginia's new Attorney General, Republican Ken Cuccinelli, stated that he was prepared to defend Virginia's law in the courts and that the state would stand firm in rejecting the federal insurance mandate. In late March, Cuccinelli filed a lawsuit against the federal government. He joined the governors and attorneys general in over three dozen states who have signaled that they will sue the federal government over the insurance mandate. Many constitutional law experts, however, predict that their chances of victory are slim.

Expected outcome

Many commentators, particularly those opposed to the new federal legislation, have argued that the provisions of federal health reform, including the health insurance mandate, are unconstitutional for their infringement on individual rights. Most legal analysts, however, argue that there is nothing unconstitutional about individual mandates, and do not expect challenges to federal law to hold up, according to the National Conference of State Legislatures. Analysts have cited the Congressional power to tax and to regulate interstate commerce as examples of federal power to impose individual mandates; one legal analyst pointed out that payroll taxes that fund Medicare are, in effect, a requirement to purchase health insurance, albeit for later in life. The 2006 Massachusetts law that requires state residents to be covered by health insurance has not been successfully challenged.

Much as states were powerless to nullify civil rights laws, some experts say, they will likewise be unable to overrule the individual health insurance mandate. Should challenges to the federal law reach the Supreme Court, several experts have predicted that the current Court would uphold the law.

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable system less equitable system more equitable
Cost Efficiency very low neutral very high

If Virginia's law holds up in the courts, it will essentially leave the present state of health care in Virginia -- which has 1 million residents uninsured -- unchanged.


Sources of Information

American Legislative Exchange Council. "Freedom of Choice in Health Care Act: How Your State Can Protect Patients' Rights."

Davey, Monica. "Health Care Overhaul and Mandatory Coverage Stir States' Rights Claims." New York Times, Sept 28, 2009.

Goldstein, Jacob. Arizona's Proposition 101 Would Block Universal Health Coverage. Oct 29, 2008.

MacNeil Lehrer Newshour. Virginia Voters Examine Health Reform. April 11, 2010.

Senate Bill No. 283.

Sluss, Michael. "Bills Challenging Insurance Mandate Advance for Full Senate Consideration." Virginian-Pilot, Jan 26, 2010.

Author/s and/or contributors to this survey

Elena Conis

Suggested citation for this online article

Elena Conis. "Virginia Takes Steps to Undo Health Reform". Health Policy Monitor, April 2010. Available at