Guide To State Requirements And Policy Choices In The Affordable Care Act PDF Download

The Affordable Care Act granted states considerable discretion over the implementation of health exchanges. Under the law as passed, states had two options: 1) they could establish their own exchanges or 2) they could leave the task to the federal government. Seeking to induce states to set up their own exchanges or take on some of the tasks involved, the federal government entered into negoatiations with state governments. These negotiations led to a continuum of state involvement in the implementation of the exchanges rather than an either/or situation in which either the states performed all the core exchange functions or the federal government performed all of them. The four core functions were: 1) eligibility and enrollment, 2) plan management, 3) consumer assistance, and 4) financial management. Currently, many states perform some of these functions but not all of them. The number of core functions a state decides to implement indicates different degrees of state control over the exchanges, ranging from no state control (federal control), to partial state control, to full state control over the exchanges. This research considered different degrees of state control over the exchanges and investigates (1) why states differ in the implementation process, especially in terms of the number of core functions a state decides to implement; and (2) what factors including state variation in the implementation process are associated with varied citizen enrollment. Using ordered logistic regression, this research found that the extent of state control over the exchanges was associated with intergovernmental conflict, financial incentives from the national government, moralistic political culture, state authority to review individual plans, state personnel capacity, and problem severity. Also, this study reported that the percent of eligible individuals who obtained insurance via health exchanges was associated with Medicaid expansion, citizen ideology, state financial capacity, health-related interest groups, and health-related nonprofit organizations. This research contributed to intergovernmental implementation theory and federalism theory by investigating the effect of the national-state negotiations on state involvement in health exchanges and policy outcomes, and the role of states compared to national government and state-national partnership in implementing health exchanges. The national-state negotiations, along with financial incentives from the national government, were successful in inducing states to take part in the exchanges. At a minimum, states fully implementing or partially involved in the exchanges did not perform worse than the national government in citizen enrollment in 2014. Also, this research suggests that policy implementers pay attention to Medicaid expansion, state administrative capacity, and nonprofit organizations for successful implementation of health exchanges.