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It has long been anticipated that 2014 would be the year in which most major elements of the Patient Protection and Affordable Care Act of 2010 (ACA) would be implemented.1 Yet even after surviving legislative, judicial, and electoral challenges, what the law actually will accomplish is uncertain. A major reason is the prominent role given to the states over the implementation of the ACA.2,3
State flexibility is a double-edged sword. By shifting some difficult decisions from the federal government, states can tailor health reform to the needs of their stakeholders. But implementing reform through the states increases the number of elected officials able to influence implementation.
Jones DK, Singer PM, Ayanian JZ. The Changing Landscape of Medicaid: Practical and Political Considerations for Expansion. JAMA. 2014;311(19):1965–1966. doi:10.1001/jama.2014.3700
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