Exchange Politics
The Affordable Care Act (ACA) required that each state set up a health insurance exchange or lose control to the federal government. Because Republicans had supported the concept before it became part of Obamacare, virtually every state was expected to cooperate and implement this core part of the law. However, 34 states refused to participate. This is a stunning miscalculation by the Obama administration. This book tells the story of what happened in the final two states to choose state control and the two that came the closest. The most intense split was not between Republicans and Democrats, but within the Republican Party. Governors were the most important people in the fight over exchanges, but did not always get their way. The Tea Party defeated the most powerful interest groups. State-level and national conservative think tanks were important allies to the Tea Party. The relative power of these groups was shaped by differences in institutional design and procedures, such as whether a state has term limits and the length of legislative sessions. Opposition was more easily overcome in states whose conditions facilitated the development of legislative “pockets of expertise.” This is a dramatic example of opponents using federalism to block national reform and serves as a warning of the challenge of inducing state cooperation in other policy domains such as the environment and education. Understanding the state-level fights over the ACA’s implementation is crucial to understanding the impact of future reforms.