title: Implementing health care reform in the United States: intergovernmental politics and the dilemmas of institutional design.
abstract: The Affordable Care Act (ACA) was enacted, and continues to operate, under conditions of political polarization. In this article, we argue that the law's intergovernmental structure has amplified political conflict over its implementation by distributing governing authority to political actors at both levels of the American federal system. We review the ways in which the law's demands for institutional coordination between federal and state governments (and especially the role it preserves for governors and state legislatures) have created difficulties for rolling out health-insurance exchanges and expanding the Medicaid program. By way of contrast, we show how the institutional design of the ACA's regulatory reforms of the insurance market, which diminish the reform's political salience, has allowed for considerably less friction during the implementation process. This article thus highlights the implications of multi-level institutional designs for the post-enactment politics of major reforms.
authors: Johnson-Shoyama Graduate School of Public Policy, 101 Diefenbaker Place, Saskatoon, Saskatchewan, Canada S7N 5B8. Electronic address: daniel.beland@usask.ca.
authors: Daniel
authors: D
authors: Béland
authors: University of California, Berkeley, Charles and Louise Travers Department of Political Science, 210 Barrows Hall #1950, Berkeley, CA 94720-1950, United States.
authors: Philip
authors: P
authors: Rocco
authors: Department of Politics and International Relations, University of Leicester, University Road, Leicester LE1 7RH, United Kingdom.
authors: Alex
authors: A
authors: Waddan
mesh_terms: D035082:Federal Government; D018166:Health Care Reform / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D062265:Health Insurance Exchanges / Q000331:legislation & jurisprudence / Q000458:organization & administration; D006801:Humans; D008484:Medicaid / Q000331:legislation & jurisprudence / Q000458:organization & administration; D058991:Patient Protection and Affordable Care Act / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D011057:Politics; D013219:State Government; D014481:United States
keywords: Affordable Care Act; Federalism; Health care; Health-insurance exchanges; Institutional design; Intergovernmental relations; Medicaid; Policy implementation; Regulatory reform; United States