University of Nevada, Reno Implementing the Affordable Care Act’s Health Insurance Marketplaces: An Analysis of Enrollment Success by Marketplace Type A dissertation submitted in partial fulfillment of the Requirements for the degree of Doctor of Philosophy in Political Science by Amber J. Joiner Dr. William Eubank/Dissertation Advisor December, 2018 © by Amber J. Joiner 2018 All Rights Reserved THE GRADUATE SCHOOL We recommend that the dissertation prepared under our supervision by AMBER J. JOINER Entitled Implementing The Affordable Care Act’s Health Insurance Marketplaces: An Analysis Of Enrollment Success By Marketplace Type be accepted in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY William Eubank, Ph. D., Advisor John Marini, Ph. D., Committee Member Robert Ostergard, Ph. D., Committee Member Tom Harris, Ph. D., Committee Member Daniel Cook, Ph. D., Graduate School Representative David W. Zeh, Ph. D., Dean, Graduate School December, 2018 i Abstract On October 1, 2013, the most visible component of the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA) went live. Health insurance marketplaces provided residents with a place to shop and receive subsidies for insurance plans that contained the essential health benefits required by the ACA. The ACA required each state to establish an exchange, but it also provided flexibility so if a state elected not to (or could not) build its own, the federal government would implement the marketplace. A handful of states chose a hybrid implementation, which used the federal HealthCare.gov website but left certain decisions to the states. In the end, twice as many states chose to use the federal HealthCare.gov website compared to states that created a state-based marketplace and website. This trifurcated approach to implementing the health insurance marketplaces where residents were either served by a federally- facilitated, state-based, or hybrid marketplace, provides a unique situation for comparison and analysis relating to federalism and public policy implementation. This policy analysis examines the implementation of the ACA’s health insurance marketplaces in all 50 states and the District of Columbia. It discusses enrollment success during the first five open enrollment periods across all three marketplace types. Among the federally-facilitated, state-based, or hybrid marketplaces, was one type more successful than the others at enrolling residents in health insurance? What factors may have played a role in success or failure? This study discusses the ACA marketplaces as a case study in federalism and public policy implementation. ii Dedication This dissertation and my Ph.D. would not have been possible without the support of my family, to whom I dedicate this work. To my parents, Joyce and Richard Joiner: Thank you for your infinite love and encouragement throughout my life. To my twin, Amy Joiner, and sister, Shelly Joiner Capurro: Thank you for being incredibly thoughtful and kind big sisters who always cheer me on. To my husband, Kyle Davis: I am eternally grateful to you for your unconditional love, hard work, and enabling of all of my academic and professional pursuits (no matter how insane or taxing on our family). To my beloved children, Eleanor and Stewart Davis: Your hugs and laughter make all my hard work worthwhile. Although this project and my work have taken me away from you far more than I would have liked, I hope to have been a good role model for you in three lessons: Never stop learning, never give up on your dreams, and never sit on the sidelines. iii Acknowledgements I am indebted to my chair and committee members for agreeing to help me through this process. Drs. Marini, Ostergard, Cook, and Harris each brought unique expertise to this project and inspired intriguing ideas for future research during their questioning at my defense. I am truly grateful to Dr. Eubank for his generosity of time as my chair and for sharing his extensive knowledge of health care policy with me. Early in my studies at the university, key teachers and mentors inspired me to learn more about the world and public policy. I am thankful to Dr. Robert Morin for making learning about the legislative process and state and local government fascinating. His classes inspired me to go into the legislative and public policy world. I am also grateful to Ronna Liggett, my former Intercollegiate Speech and Debate Coach, for her mentorship throughout the last 25 years. She not only helped me develop my skills in analyzing policy, thinking critically, and being an advocate, but she has been an incredible role model for how to be a global citizen. The early phases of this dissertation were supported by two outstanding faculty members, Dr. Leah Wilds, and Dr. Stacy Gordon Fisher. I thank them for making me a better writer, researcher, and by their examples a better teacher and mentor for my own students at the University. The inspiration for this dissertation came from my personal experiences tracking and participating in the implementation of the Affordable Care Act in Nevada through my various professional roles during the last decade. I am grateful to my many colleagues in Nevada who have worked beside me on this historic policy. This project was a rare opportunity to step back from my own experience and compare it to the rest of the nation. iv Table of Contents Abstract .....................................................................................................................i Dedication .................................................................................................................ii Acknowledgements ...................................................................................................iii Table of Contents ......................................................................................................iv List of Tables ............................................................................................................vi List of Figures ...........................................................................................................vii Introduction ...............................................................................................................1 Chapter 1: Literature Review .....................................................................................10 Federalism & Intergovernmental Relations ...................................................10 Public Policy Implementation ........................................................................13 Chapter 2: The Affordable Care Act ..........................................................................18 Chapter 3: Analysis ...................................................................................................34 Federalism and the ACA ................................................................................35 Court cases .........................................................................................45 Data Challenges in Intergovernmental Relations ..............................50 Selecting a Plan ......................................................................50 Effectuating a Plan .................................................................52 Accounting for State Size ......................................................55 Three Marketplace Comparison Cases ..........................................................55 Marketplace Comparison Case #1 .....................................................56 Marketplace Comparison Case #2 .....................................................66 Marketplace Comparison Case #3 ....................................................72 Four Key Factors in Public Policy Implementation .......................................78 v Bureaucracy .......................................................................................78 Political Disposition ..........................................................................82 Resources ..........................................................................................88 Federal Grants ........................................................................88 Technology ............................................................................96 Communication .................................................................................106 Chapter 4: Conclusion ................................................................................................115 References .................................................................................................................124 vi List of Tables Table 2.1 ...................................................................................................................25 Table 2.2 ....................................................................................................................27 Table 3.1a ...................................................................................................................60 Table 3.1b ..................................................................................................................61 Table 3.1c ...................................................................................................................62 Table 3.2a ...................................................................................................................69 Table 3.2b ..................................................................................................................70