title: Polarized stakeholders and institutional vulnerabilities: the enduring politics of the Patient Protection and Affordable Care Act.
abstract: OBJECTIVE
  We conducted a comparative study of how state-level political stakeholders affected the implementation of 3 major reforms within the Patient Protection and Affordable Care Act (ACA). Our goal was to analyze the effects of policy legacy, institutional fragmentation, and public sentiments on state obstruction of the reform.
  
  
  METHODS
  We gathered quantitative and qualitative evidence to generate cross-case comparisons of state implementation of 3 reform streams within the ACA: health insurance exchanges, Medicaid expansion, and regulatory reform. Our sources included secondary literature, analysis of official decisions, and background interviews with experts and public officials.
  
  
  RESULTS
  We found that state-level opponents of the ACA were most likely to be successful in challenging reforms with few preexisting policy legacies, high institutional fragmentation, and negative public sentiments. Reforms that built on existing state legislation, avoided state veto points or offered lucrative fiscal incentives, and elicited less negative public reaction were less likely to be contested.
  
  
  CONCLUSIONS
  Our findings point to the importance of institutional design for the role of political stakeholders in implementing reforms to improve the cost, quality, and availability of medical treatments. Although other research has found that political polarization has shaped early ACA outcomes, comparative analysis suggests political stakeholders have had the highest effect on reforms that were particularly vulnerable.
authors.affiliation: Johnson-Shoyama Graduate School of Public Policy, Saskatoon, Saskatchewan, Canada. Electronic address: daniel.beland@usask.ca.
authors.forename: Daniel
authors.initials: D
authors.lastname: Béland
authors.affiliation: Charles and Louise Travers Department of Political Science, University of California, Berkeley, California.
authors.forename: Philip
authors.initials: P
authors.lastname: Rocco
authors.affiliation: Department of Politics and International Relations, University of Leicester, Leicester, United Kingdom.
authors.forename: Alex
authors.initials: A
authors.lastname: Waddan
mesh_terms: D001294:Attitude to Health; 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 / Q000458:organization & administration*; D011057:Politics; D013219:State Government; D014481:United States
keywords: Medicaid expansion; Obamacare; Patient Protection and Affordable Care Act; health care reform; health insurance exchanges; regulatory reform