Implementing Obamacare: Intergovernmental Battles over the Creation of Health Insurance Exchanges by David K. Jones A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Health Services Organization and Policy) in the University of Michigan 2014 Doctoral Committee: Associate Professor Scott L. Greer, Chair Professor Peter D. Jacobson Research Associate Professor Helen G. Levy Professor Barry G. Rabe © David K. Jones 2014 Dedication For Sarah, Olivia, Anne, and Thomas ii Acknowledgements Thank you to all the people who made my doctoral experience such a pleasure. First, Scott Greer was a wonderful adviser, mentor, and committee chair. He was generous with his time and provided important guidance. I can trace most of my publications thus far to conversations with Scott. The rest of my dissertation committee was equally wonderful. Peter Jacobson was a thorough and trusted sounding board on multiple projects. Helen Levy provided extensive insight on the details of the ACA and how they came to be. Barry Rabe helped navigate the territory between the fields of public health, public policy, and political science. All four members of my committee were also exceptionally kind and supportive. Many other people provided guidance along the way. I particularly enjoyed working as a teaching assistant for Rich Lichtenstein. Daniel Eisenberg and Rich Hirth provided important service as directors of the Health Services, Organization, and Policy (HSOP) doctoral program in the Department of Health Management and Policy. Kyle Grazier and Holly Jarman offered invaluable advice during my job search. I loved working for two years as a research assistant for the Robert Wood Johnson Health Policy Scholars. I am also grateful for the help of many professors in the University of Michigan’s Political Science Department. Thank you to my fellow students in HSOP. Special thanks to those ahead of me whose assistance meant more than they realize, including Edward Miller, Sarah Gollust, Pam McCann, and Kate Bradley. The political science cognate in HSOP was a crucial source of support and encouragement, including Phil Singer who has been a fantastic collaborator and friend. I am grateful for many other mentors. It has been a rewarding and delightful experience to work with Colleen Grogan of the University of Chicago. Jeanine Pommier’s assistance was critical during my two summers at L’Ecole des Haute Etudes en Santé Publique in Rennes, Frances. Encouragement from Suzanne Havala-Hobbs and Ned Brooks at the University of North Carolina was a major reason I applied to doctoral programs in the first place. Jonathan Oberlander has been a wonderful collaborator – despite our differing baseball allegiances. I am grateful for the many people whose assistance with logistics made this work possible. Mindy Niehaus-Fukuda helped in countless ways at every stage in my doctoral studies. Connie Rockman regularly went above and beyond on my behalf. Yvonne DeCarlo was incredibly helpful with arranging travel for research trips. Five undergraduate students provided research assistance over the course of three years through the Undergraduate Research iii Opportunities Program (UROP). Thank you to Alex Coburn and Sahil Gosain (2011-2012), Alex Bernard and Hannah Mesa (2012-2013), and Alexa Abbott (2013-2014). Many people facilitated work experience that I drew on regularly throughout this research. In particular, I would like to thank former Representative Margaret Henbest and Representative John Rusche of the Idaho House of Representatives, the Honourable Rob Merrifield and his staff in the Canadian House of Commons, and the staff of Congressman Charles Rangel’s district office in Harlem, as well as Pam Silberman and everyone at the North Carolina Institute of Medicine. I would like acknowledge the many state and federal policymakers and industry leaders who agreed to be interviewed for this project. This dissertation would not have been possible without their willingness to share their time and insights. I am also grateful for the organizations that provided complimentary or reduced registration to their policy conferences so I could interview policymakers, including the National Academy for State Health Policy (NASHP), the National Association of Insurance Commissioners (NAIC), the Council of State Governments (CSG), and the National Committee for Quality Assurance (NCQA). I am grateful for funding received from a variety of sources, including grants and fellowships from the Rackham Graduate School at the University of Michigan, the Blue Cross Blue Shield of Michigan Foundation Student Research Award, the Agency for Healthcare Research and Quality doctoral traineeship, the Martha and Ernest Hammel Award, the Jim Bernstein Health Policy Fellowship, the Jean Monnet Fellowship, and the Department of Health Management and Policy. Most importantly, I thank my family. My parents Debra Bingham, Jeffrey Jones, and Kent Hamilton are a constant source of support, inspiration, and love. I am grateful for my amazingly devoted grandparents, as well as for Pamela Cooper and my extended family. I am pleased to dedicate this work to my children Olivia, Anne, and Thomas, all of whom were born while I was in graduate school. They bring so much joy into my life. My wife, Sarah Sacuto, is a wonderful partner and friend. I am extremely proud of all that she has accomplished during our time in Ann Arbor and cannot adequately express my gratitude for her support. iv Table of Contents Dedication ....................................................................................................................................... ii Acknowledgements ........................................................................................................................ iii List of Tables ................................................................................................................................. vi List of Figures ............................................................................................................................... vii List of Appendices ....................................................................................................................... viii Abstract .......................................................................................................................................... ix Chapter 1 - Introduction .................................................................................................................. 1 Chapter 2 - Integrated Theoretical Framework ............................................................................. 22 Chapter 3 - 50-state overview ....................................................................................................... 57 Chapter 4 - Michigan .................................................................................................................... 90 Chapter 5 - Mississippi ............................................................................................................... 150 Chapter 6 - Idaho ........................................................................................................................ 195 Chapter 7 - New Mexico ............................................................................................................. 251 Chapter 8 - Conclusion ............................................................................................................... 292 Appendices .................................................................................................................................. 321 References ................................................................................................................................... 333 v List of Tables Table 1- State Decision-Making and Partisan Control, as of November 2011 ............................... 8 Table 2- State Decision-Making and Exchange Grants Received (in millions) as of November 2011................................................................................................................................................. 9 Table 3 – 2008/2012 Vote vs. Partisan Control of States Led by a Republican Governor and Undecided as of Nov 2011 ............................................................................................................ 17 Table 4 - Summary of Four Case Study States ............................................................................. 17 Table 5 - Distribution of Number of Legislators per State ........................................................... 36 Table 6- Term Limits in State Legislatures .................................................................................. 39 Table 7 - Federal Exchange Grants Awarded by Type of Exchange, as of March 2013.............. 67 Table 8 - Roll Call of Floor Votes on Legislation to Create Exchanges, Pre-and Post-ACA ...... 68 Table 9 – Michigan’s Political and Demographic Context ........................................................... 91 Table 10 - House Health Policy Committee Roll Call on SB 693, November 29, 2012 ............ 128 Table 11 – Mississippi’s Political and Demographic Context .................................................... 152 Table 12– Idaho’s Political and Demographic Context .............................................................. 196 Table 13 - New Mexico’s Political and Demographic Context .................................................. 252 Table 14 – Influence of Key