Implementing Obamacare: Intergovernmental Battles Over the Creation of Health Insurance Exchanges.

Health Politics;Obamacare;Health Reform;Health Insurance;Government Information;Law and Legal Studies;Political Science;Medicine (General);Public Health;American and Canadian Studies;History (General);Social Sciences (General);Government Information and Law;Health Sciences;Social Sciences;Health Services Organization & Policy

Jones, David K.Levy, Helen G. ;

University of Michigan

关键词: Health Politics;    Obamacare;    Health Reform;    Health Insurance;    Government Information;    Law and Legal Studies;    Political Science;    Medicine (General);    Public Health;    American and Canadian Studies;    History (General);    Social Sciences (General);    Government Information and Law;    Health Sciences;    Social Sciences;    Health Services Organization & Policy;   

Others  :  https://deepblue.lib.umich.edu/bitstream/handle/2027.42/108945/davidkj_1.pdf?sequence=1&isAllowed=y

瑞士|英语

来源: The Illinois Digital Environment for Access to Learning and Scholarship

【 摘 要 】

The Affordable Care Act’s (ACA) implementation has been marked by deep political division. Health insurance exchanges were a provision expected to elude controversy given their history of Republican support and since states choosing not to create an exchange would cede control to the federal government. Yet, only 17 states chose to create their own exchange, including only one led entirely by Republicans. Why did so few states opt for maintaining control? Partisanship, the notion that Republicans refused to support an idea endorsed by President Obama and other Democrats, is one of the most common explanations given for opposition. However, I argue that focusing on partisanship obscures important aspects of the policymaking process.No one variable explains each state’s decision. Instead, I develop a framework to integrate lessons from multiple theoretical perspectives. The framework includes a focus on the strategic actors attempting to influence policy. It also acknowledges that these strategic interactions take place within a specific state context that is shaped by institutional design, prior policy decisions, and partisanship.Each state’s context is also nested within the broader national context.I use a grounded theory approach to conduct comparative case studies.I focus on the two states that came the closest to setting up an exchange (Michigan and Mississippi) and two of the last states to opt for state control (Idaho and New Mexico). I conducted 154 interviews with policymakers in 24 states and at the federal level between June 2011 and March 2014, including approximately 18 interviews per case study state.I find that gubernatorial support was a necessary, but not sufficient condition for a state to decide to create an exchange. In many states the key division was not between Democrats and Republicans, but was within the Republican Party. Tea Party opposition could be overcome if the legislature contained ;;pockets of expertise,” particularly influential legislators with deep policy and institutional knowledge.Term limits and the timing of the legislative calendar affected who was empowered to make decisions, as did state-specific path dependent forces. Flexibility by the Obama administration helped some states but ironically emboldened opponents in others.