July 2016
In this essay, Richard P. Nathan reviews several issues affecting the implementation of the Patient Protection and Affordable Care Act of 2010 (commonly know as ACA). It’s no surprise that there are many implementation questions for an act still only in its third year of full operation. But there are reasons to believe that the ACA will always be a “work in progress.” A central truth about the ACA is that its successful implementation depends on the actions of many people and organizations over which the federal government has limited authority. The Supreme Court’s decision in 2012 made this point emphatically with respect to states’ decisions to expand (or not expand) Medicaid. Yet the ACA not only relies on the decisions of governors and state legislators; it is also affected by the many choices made by insurance companies, consumers, employers, health care providers, multiple state agencies, and others to work. And though the federal government has some leverage over all of these players, the latter respond to many other, often changing variables and interpretations of their responsibilities.
States are in the middle of this complex system and its flux, and they will surely make many new decisions and revisions so long as the ACA exists. For that reason, the ACA Implementation Research Network — a joint program of the Brookings Institute and the Rockefeller Institute —is especially valuable because of its persistent presence in and deep connections within states. Our field research teams are following new developments on the ground, and they can put recent changes in their longer-term context and assess their real significance. The Rockefeller Institute thanks Senior Fellow Dick Nathan and his partner in leadership of the Network, Alice Rivlin, for establishing the project and applying it to key questions about exchange participation and competitiveness, consumer assistance and navigation, and other emerging issues.
