The Future of Health Care Reform: What Is Driving Enrollment?

What is it about?

This article examines enrollment in the Affordable Care Act's two main coverage mechanisms - health insurance exchanges and Medicaid - across states to understand the factors that drive higher enrollment in each. Critically, we discuss the implications of these findings in light of Republican efforts to 'repeal and replace' the Affordable Care Act.

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Why is it important?

We demonstrate that while partisanship drives state decisions to expand Medicaid or adopt a state based exchange, it has minimal impact on program enrollment. Instead, exchange enrollment is driven by public support for President Obama and economic conditions and Medicaid enrollment is driven by the administrative capacity of the state's bureaucracy. This suggests that even if partisan efforts to alter the ACA at the national level are successful, enrollment itself will be driven by a different set of factors.