Implementing Health Reform: Intergovernmental Bargaining and the Affordable Care Act

Implementation of the insurance-exchange and Medicaid-expansion provisions of the Affordable Care Act offers an opportunity to analyze the sources and extent of state and federal government leverage in bargaining over the rollout of amajor federal program. What stands out from this study is state officials'ability to leverage their administrative capacity and policy expertise as well as their power to decline participation in federal programs in order to influence implementation of a federal initiative. State officials' influence is heightened when the program depends on state participation to achieve key federal objectives, when state threats to decline participation are meaningful, and when state nonparticipation threatens the success of a signature item on a president's policy agenda.