Implementing the Affordable Care Act Health Insurance Exchanges: State Government Choices and Policy Outcomes

Intense partisan conflict characterized the Affordable Care Act's passage and continues to influence its implementation. The Act granted state officials significant discretionary authority over the implementation of health insurance exchanges and Medicaid expansion. Decisions by state officials vary from full state involvement to partial involvement to refusal to administer a state health exchange or expand Medicaid. The federal government administers a health exchange in those states choosing not to operate an exchange. The article examines whether variation in state program choices affects citizen decisions to enroll in an exchange. Also examined is whether health insurance premiums vary by which level of government administers the exchange. The analysis provides evidence that the Act's goals of increased enrollment in health insurance and affordable premiums are influenced by state government decisions on the extent of state involvement in health exchanges and Medicaid expansion.