Boston University.
J Health Polit Policy Law. 2020 Aug 1;45(4):661-676. doi: 10.1215/03616878-8255577.
The fight over health insurance exchanges epitomizes the rapid evolution of health reform politics in the decade since the passage of the Affordable Care Act (ACA). The ACA's drafters did not expect the exchanges to be contentious because they would expand private insurance coverage to low- and middle-income individuals who were increasingly unable to obtain employer-sponsored health insurance. Instead, exchanges became one of the primary fronts in the war over Obamacare. Have the exchanges been successful? The answer is not straightforward and requires a historical perspective through a federalism lens. What the ACA has accomplished has depended largely on whether states were invested in or resistant to implementation, as well as individual decisions by state leaders working with federal officials. Our account demonstrates that the states that have engaged with the ACA most consistently appear to have experienced greater exchange-related success. But each aspect of states' engagement with or resistance to the ACA must be counted to fully paint this picture, with significant variation among states. This variation should give pause to those considering next steps in health reform, because state variation can mean innovation and improvement but also lack of coverage, disparities, and diminished access to care.
关于医保交易所的争议，正是自平价医疗法案（ACA）通过以来，医保改革政治迅速演变的缩影。ACA 的起草者原本并未料到医保交易所会引发争议，因为这些交易所旨在扩大私人保险的覆盖范围，覆盖那些越来越难以获得雇主赞助的医疗保险的低收入和中等收入人群。然而，医保交易所却成为了奥巴马医改战争的主要前线之一。医保交易所成功了吗？答案并不简单，需要从联邦制的角度进行历史分析。ACA 所取得的成就在很大程度上取决于各州是否参与或抵制实施，以及州领导与联邦官员合作的个人决策。我们的叙述表明，那些最积极参与 ACA 的州似乎在交易所相关方面取得了更大的成功。但是，为了全面描绘这一图景，必须计算出各州参与或抵制 ACA 的各个方面，因为各州之间存在显著差异。这种差异应该让那些正在考虑医保改革下一步的人深思熟虑，因为州的差异可能意味着创新和改进，但也可能意味着缺乏覆盖、差异和医疗服务获取受限。
