The political leanings of the South don’t tell the whole story behind resistance to the Affordable Care Act, says a report written by West Virginia University Public Administration Professor L. Christopher Plein.

“Some of the most vocal opposition to the ACA has been from the southern states, so it is convenient to dismiss their decisions as electoral politics or ideological differences,” said Plein, one of the lead researchers in the Rockefeller-Fels study of ACA implementation. “But that would be an incomplete picture.”

Although politics and partisanship played a significant role, he found that the “turbulent opposition” of the southern states was also rooted in their past history and administrative capacity as well as underlying market and demographic factors.

Regional reports for the southern states were presented at the National Press Club in Washington D.C. Monday (Aug. 25). The reports are part of the 35-state ACA implementation project of the Rockefeller Institute of Government of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania. The event was also sponsored by WVU and the GOVERNING Institute. The overview and regional reports may be accessed here.

The research paid close attention to two aspects of the law – the establishment of health care exchanges and the expansion of Medicaid – because in many ways they were the areas closest to the states’ policy-making responsibilities.

“For many of the southern states, establishing health insurance exchanges – online marketplaces for individuals to sign up for insurance coverage – was problematic,” said Plein. “Many deferred because they felt a lack of guidance from the federal government. Coupled with a looming Supreme Court decision, state policy makers were put in a difficult position.”

In the South, only three out of 16 states established state-run exchanges. The District of Columbia, which the U.S. Census Bureau considers part of the South, also established its own exchange. Eleven of the 16 states decided to join the federal exchange and three formed state-federal partnerships.

Furthermore, only five of the southern states along with the District of Columbia chose to expand Medicaid. Plein found that some states refrained from expanding Medicaid because of a complicated history with the program that had resulted in budgetary crises associated with its cost.

“The Affordable Care Act is one of the most significant pieces of public policy that has been enacted in the United States in the past 50 years. It is sweeping and contentious,” said Plein. “The success of its implementation relies largely upon the states, so taking a closer look at their efforts will bring a greater understanding about American health care reform.”

Plein is the Eberly Family Professor for Outstanding Public Service in the Department of Public Administration of the Eberly College of Arts and Sciences.

“Chris Plein has been one of the Rockefeller Institute’s best field research associates since he began working with us as part of our welfare reform network in 1997,” said Rockefeller Institute Director Tom Gais. “I’m delighted that he’s now helping us plan and lead our nationwide research on the implementation of the Affordable Care Act. His analysis of recent reactions to the ACA in the southern states is insightful and thought-provoking, and it’s especially good at revealing the diversity of responses among these states.”

The 2010 national law created new rules for private and public health insurers, employers and citizens in order to improve health insurance and provide the opportunity to purchase health insurance for more of the 60 million Americans that did not have it. It faced much opposition and a troubled rollout that had real consequences at the state level.

“On one level it’s about social policy reform, extending insurance coverage to millions of Americans,” Plein said. “On another level, it’s about market reform that will have a significant impact on the health care industry – insurance companies, health care providers, hospitals, pharmaceutical companies and medical device manufacturers.”

Plein said that patterns are starting to emerge, but the research is still in its initial phase and many questions will arise over time. “What will happen in the re-enrollment period? Will states revisit their decisions on exchanges? Will states that were sitting on the sidelines decide to expand Medicaid?”

He said that the research network is committed to taking a long look at the implementation. Field researchers are tapped in to the political, economic, social and cultural activities in their states and provide a rich picture of what is happening in the states in addition to statistical trends and administrative data.

Plein also led the research for the West Virginia report. His findings showed that West Virginia is an excellent representation of how states should take into account practical concerns when making policy decisions while still acknowledging the political backdrop of electoral cycles and pressures.

“West Virginia was an early adopter of legislation for an exchange, but after conducting actuarial analysis decided to abandon those plans and take a hands-off approach to a federal-state partnership,” he said. “Based on practical considerations, not just political ones, the state determined that the number of individuals that would likely be involved in the exchange would be fairly minimal, making the large startup cost unacceptable.”

He says that West Virginia has also demonstrated administrative innovation and flexibility in their expansion of Medicaid. Important stakeholders in the state, including the West Virginia Hospital Association, supported this course of action. Furthermore, the Department for Health and Human Resources and the Bureau for Medical Services took a proactive and aggressive approach to enrollment by identifying potential applicants through SNAP (food stamp) enrollment lists.

Finally, one of the key findings from the report was West Virginia’s involvement of non-governmental actors – the intermediaries, both formal and informal – who are helping individuals navigate through the new insurance and Medicaid laws.

The dynamics of the ACA have sparked interest in the American policy reform. Scholars will continue to study the historic context and interpret the policy decisions as well as federal and state capacity to implement these changes on a broad scale. “Dr. Plein’s participation in this national study is an indication of not only his recognized expertise in this policy area, but also serves as a preview of the type of policy analysis that scholars in WVU’s new School of Politics and Policy will contribute to important state and national policy debates,” said John Kilwein, chair of the WVU’s Department of Public Administration.

Monday’s event was broadcast live, and rebroadcast later, on the public affairs network C-SPAN.

For more information, contact Chris Plein at 304.293.7974 or



CONTACT: Devon Copeland, Eberly College of Arts and Sciences

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