While the ACA established federal minimum standards, it also left considerable room for state participation and design flexibility in implementation of its insurance market reforms, the establishment of the Health Insurance Marketplaces (HIMs), and the implementation of Medicaid.

As such, the design and effects of the ACA will differ across the states as a function of different policy choices made. Some states demonstrated a strong and consistent commitment to the law’s implementation, while others chose to play a limited role in implementation or no role at all.

Researchers at the Urban Institute and Georgetown University’s Health Policy Institute assessed the state of ACA implementation in eight states that exhibit varying levels of support for the law. The findings are contained in a series of nine papers. These papers include an overview brief that synthesizes key findings and discusses broad implications, as well as eight additional briefs that summarize findings for different kinds of states on a particular topic, including:

  • coverage expansion potential;
  • federal funding flows;
  • information technology (IT) system development;
  • eligibility determination and enrollment outreach;
  • insurance plan participation, competition and premiums;
  • insurance market reforms;
  • Small Business Health Options Program (SHOP) development; and
  • provider capacity.
Table 1