A brief note on ACA implementation hurdles and delays

Maybe I’m observing a skewed slice of the media, but it seems like many are blaming ACA implementation issues and delays on the Obama Administration or inherent flaws in the law itself. Is that fair? Maybe. Is it the whole story? Hardly.

Harold already noted that the Supreme Court’s decision to make the Medicaid expansion a state option threw in a monkey wrench, and few saw it coming. He also mentioned the limited resources that Congress has made available for implementation and the political gridlock on the issue that prevents sensible adjustments.

It should, however, also be said that states have a huge role to play in facilitating or interrupting the implementation glide path. For reasons I find completely reasonable — though still risky — many officials delayed putting full weight behind implementation until after the the Supreme Court passed judgement and the 2012 elections were decided. Some have put their full weight behind impeding implementation, which is their right. However, the active opposition to implementation is not a design flaw or the Administration’s doing. (I’m passing no judgement on it here. Just pointing out the obvious.)

There shouldn’t be much dispute about this. David Jones and Scott Greer wrote the same thing in a recent paper in the American Journal of Public Health.

Many Republican governors and legislative leaders delayed making decisions until after the Supreme Court upheld the constitutionality of the ACA and President Obama won reelection. […]

[One] view is that Republicans will continue attempts to undo the law by remaining uncooperative. Because the ACA is so closely associated with President Obama and Democrats, many Republicans see little to gain politically by supporting their state’s exchange, but much to be gained by helping it fail. […]

However, even if these governors are willing to support implementing components of the ACA, they could be blocked by coalitions of legislators whose incentive is to appeal to the preferences in their districts rather than in the entire state. For example, the Republican-controlled Michigan Senate was able to prevent the creation of a partnership exchange despite support from Governor Rick Snyder (a Republican) and approval from the Department of Health and Human Services, by not allowing state agencies to spend federal grants they had received.

Their whole paper is worth a read. It’s brief and, I think, ungated.

Implementation is a long, hard road. To be sure, it’s made harder by the nature of some aspects of the law itself. I have little doubt the Administration has made some errors in planning, which should be expected of any human endeavor. But it’s also clear that there are other forces at work.


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