Hybrid federalism, partisan politics, and early implementation of state health insurance exchanges. Publius 43 (Summer): 368–91

A central provision of the Affordable Care Act is establishment of state-level health exchanges. While states are given the opportunity to develop and administer these private insurance marketplaces, their plans must meet certain minimum standards or risk preemption by the federal government. This policy design establishes a hybrid model of intergovernmental policy making, which may serve to heighten conflict during implementation and further polarize states’policies. Using new data on states’efforts to establish exchanges and repeated-events duration modeling, we examine states ’ early exchange implementationçidentifying a key role for ideological and partisan considerations, as well as the implications of a federal policy design that puts conservative states in the difficult political position of choosing between resisting a law they oppose and preventing further federal intrusion. In March 2010, President Obama signed into law the Affordable Care Act (ACA) to expand access to and affordability of health insurance for uninsured and underinsured Americans. On the same day, Attorneys General from fourteen states joined in one of two lawsuits against the federal government challenging the constitutionality of this law; in the months that followed, another thirteen states joined the suits (Jacobs and Skocpol 2010; Joondeph 2011). Now, three years since enactment of the ACA, the intensity of political conflict surrounding its implementation has not lessened. In fact, much of the conflict has simply been devolved to the states as a result of its intergovernmental policy design, which calls on state governments and their state-regulated insurance markets to develop, provide, and deliver many of the federal benefits offered by the law. This article examines the significant variation in states ’ early implementation of a key provision of the law: state health insurance exchanges, which represent both an essential element of the reform and an area of intense intergovernmental politics. Health insurance exchanges constitute a central provision of the ACA. To qualify for federal subsidies and tax credits to help offset the high price of healt