| Sumario: | A central provision of the Affordable Care Act is establishment of state-level health exchanges. While states are given the opportunity to develop and administer these private insurance marketplaces, their plans must meet certain minimum standards or risk preemption by the federal government. This policy design establishes a hybrid model of intergovernmental policy making, which may serve to heighten conflict during implementation and further polarize states’ policies. Using new data on states’ efforts to establish exchanges and repeated-events duration modeling, we examine states’ early exchange implementation—identifying a key role for ideological and partisan considerations, as well as the implications of a federal policy design that puts conservative states in the difficult political position of choosing between resisting a law they oppose and preventing further federal intrusion.
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