You Can't Make Me Do It: State Implementation of Insurance Exchanges under the Affordable Care Act


  • Simon F. Haeder is a doctoral student in political science and a master's student in agricultural and applied economics at the University of Wisconsin–Madison. His research interests include health care policy, regulatory policy making, and theories of the policy process. He is currently working on several research projects in health policy focusing on the implementation of the Affordable Care Act and insurance regulation. He is also investigating the incidence and effect of regulatory lobbying. E-mail:

  • David L. Weimer is Edwin E. Witte Professor of Political Economy at the University of Wisconsin–Madison. His recent research has focused on health policy issues, especially the impact of report cards and regulation on health care quality and the governance of U.S. organ transplantation. He is past president of the Association for Public Policy Analysis and Management, current president of the Society for Benefi t-Cost Analysis, and fellow of the National Academy of Public Administration. E-mail:


The Patient Protection and Affordable Care Act (ACA) of 2010 has been one of the most controversial laws in decades. The ACA relies extensively on the cooperation of states for its implementation, offering opportunities for both local adaptation and political roadblocks. Health insurance exchanges are one of the most important components of the ACA for achieving its goal of near-universal coverage. Despite significant financial support from the federal government, many governors and legislatures have taken actions that have blocked or delayed significant progress in developing their exchanges. However, many state commissioners of insurance have played constructive roles in moving states forward in exchange planning through their expertise, leadership, and pragmatism, sometimes in spite of strong political opposition to the ACA from governors and legislatures.