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Institutional Design of the ACA Health Insurance Exchanges: Factors Affecting Policy Implementation In State Administration

Author: SHIHYUN NOH and CHRISTIAN L. JANOUSEK
Published in JHHSA, Vol. 41 No. 2

In state implementation of the Affordable Care Act (ACA) health insurance exchanges, sixteen states decided to create and administer their own exchanges, determining the institutional location of the exchanges. This institutional design of implementing organizations affects aspects of state policy implementation of the health exchanges, reflecting the intentions of state officials to exert control over the administration of operations and other decisions such as funding sources. This research examines whether state decisions regarding agency assignment of the ACA health exchanges were associated with political, economic, and historical-cultural explanations. This study provides evidence that, in the decision of the location of health insurance exchanges, state officials were influenced by the factors of state budget shortfalls and state histories of creating independent agencies, but not by divided government, compound divided government and state personnel capacity.
Keywords: institutional design of implementing organizations, the location of ACA health exchanges, state budget shortfalls, state histories of creating independent agencies

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