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Within the far-reaching and multi-layered realm of policy and reform, government at the state level plays an essential role. Consider the federally enacted PPACA’s individual mandate which sought to increase the number of consumers who receive insurance coverage and, therefore, greater access to care. In a system that is already stretched beyond capacity and confronting a nursing shortage, how can the health care system meet this increased demand? Since state boards of nursing determine scope of practice, it is important to stay up to date and current with the policies and regulations that are created by the state board of nursing. a cohesive response that addresses the following: 1) What are the most recent regulations promulgated through your state board of nursing for advanced practice? 2) How are the state regulations supported within your place of employment? ( 3) How do the states differ in terms of scope of practice? What impact does this have on professional nurses across the United States? The authors provide an analysis of varying state health care policies, with a basic premise that health care risk is either “pooled”—shared, or “actuarial”—segmented by risk level. Most states have taken a segmented approach to health care, and therefore, have not solved health care issues such as rising costs and access to care. The authors maintain that federal action is needed to create a uniformed approach to

health care. This article provides details on a 50-state study of Medicaid spending. The authors concluded that political and economic factors can positively predict individual state Medicaid spending, and that actual need has a negative impact on spending. In conclusion, a uniform, federal structure may be the only method to ensure equal access to Medicaid. The enrollment and retention of eligible children in Medicaid and Children’s Health Insurance Program (CHIP) is a health care concern. The article concludes that some state processes have mitigated this issue but other requirements, such as providing citizenship documentation, may have a detrimental effect. Therefore, these concerns should be incorporated into the implementation on PPACA of 2010. The authors use the changes instituted by the state of Texas in regard to the licensing of nurses to illustrate the need to adapt state licensing requirements to the changing diversity and scopes of practice among nurses. The expanded role of the advanced practice nurse has led to changes in licensure, education, certification, and scope of practice definitions. The author points out that this expanded role has led to increased liability and accountability concerns as well. Those nursing homes receiving Medicare and Medicaid funding are subject to strict quality and safety regulations. This article examines the consequences of enforcing those federal quality standards.