Federalism and public opinion on healthcare: The design of the affordable care act's insurance exchanges and user experience with the exchanges

Abstract

Using original survey data and the 2016 American National Election Study (ANES), we examine the effects of healthcare exchange type and user experience on individuals 'support for the Affordable Care Act (ACA). States are divided into three different types of ACA exchange implementation regimes: state-run exchanges, federally operated exchanges, andmixed state-federal exchanges. We hypothesize that individuals in states running their own exchanges will demonstrate greater support for the ACA and individuals with experience using the exchanges will exhibit greater levels of support for the ACA. Results froma survey conducted in 2016 in Alabama (a federal exchange), Kentucky (a state exchange at the time), and Arkansas (a mixed state-federal exchange) support these hypotheses. These findings are also confirmed using national data from the ANES. We therefore provide evidence that local control over healthcare implementation leads to better outcomes in terms of citizen satisfaction and that citizens who have experience with exchanges established by theACA are more likely to feel positively about the law.