Which can be resolved with the hybrid system I advocated; The fed places the requirements. They are not optional. The state manages the nitty gritty of the implementation.
EG, the fed says something like:
"Individuals seeking medical care cannot be denied due to race, sex, national origin, religious belief, or sexual identity-- and cannot be denied due to a pre-existing condition. The purpose and scope of this bill is to ensure that all americans, regardless of these conditions, are able to receive quality healthcare that is affordable, to them."
Now, it suddenly goes from "Hey, I can't get my HIV meds because the fundies think my gay lifestyle is to blame, and I am cursed by god!" to "Oh darn-- you mean my swiss massages arent covered here? darn!" levels of difference.
Because the scope is "All americans", marital status is moot-- You dont get a benefit or a detriment to being married, or having children. You are mandated to be able to have quality healthcare that you can afford. If poverty rate is very high in the state, that puts extreme pressure on the state to improve that problem, so that people can afford quality healthcare. They dont get to deny access. That's the point of the fed oversight.
This kind of approach would basically destroy the very idea of private insurance for healthcare. Instead of gambling that you wont become sick, like a private ensurer does, the state would look at overall statistics for incidence of disease or injury, and amortize the annual costs over the whole taxbase. Thus, even if your have a cancer that costs multiple millions of dollars in treatment to put into 5 year remission-- your tax rate does not go up, because most residents of the state are not going to having that happen to them. The state keeps a surplus fund, or some other means of implementing such amortization, so that it is able to absorb that cost for you, per the federal mandate. Failure to be able to absorb those costs, and thus failure to meet the mandate, results in a failing grade on their audit, and federal level interventions, such as say-- the feds earmarking money to make up the shortfall. (Nope, no stadium this year-- you done fucked up. We wont let you.)