First of all, it's "forcefully". Second of all, federal law supercedes state law. The ACA was passed at the federal level, therefore it dictates how state law should be formed. A majority of congress, regardless of which way they sway, approved the law, and it was signed into law, ok? And yes, our healthcare was ranked 39th in the world at one point. And the ACA was passed in order to start improving on that ranking, ok? Eventually, we'll make it to single-payer healthcare and will be on par with other countries.