Year of Publication



Martin School of Public Policy and Administration

Date Available


Executive Summary

The Patient Protection and Affordable Care Act of 2010 consists of several provisions designed to promote the obtainment of affordable health insurance coverage for all Americans. In order to facilitate access to information on available prices and policies for this coverage, the law requires states to decide whether to operate their own healthcare insurance exchange or join a partnership or federal exchange. While many states proceeded with the implementation of state-based exchanges despite a challenge to the law in the Supreme Court, other states did not. This paper explores the influence that certain and health market characteristics may have had in a state’s decision on whether to adopt a state-based exchange prior to the Supreme Court judgment on June 28, 2012.

For my analysis, I develop a series of Kaplan-Meier survival models for my variables to identify patterns in the risk of adoption. Time to adoption of state-based exchanges serves as my dependent variable. In order to assess the relationships between variables and time to adoption, I also produce a multivariate Weibull regression model that shows hazard ratios associated with adopting by the designated date. For this model, I include factor scores for my federal and state political variables to address multicollinearity.

The results of the Kaplan-Meier models demonstrate states that are more liberal politically were more likely to adopt state-based healthcare insurance exchanges prior to the Supreme Court judgment. Further analysis of the variables in my regression model shows that certain state-level political characteristics, encompassed within one of the factor scores, had influence on a state’s decision. Specifically, the number of Democrats in a state’s executive office and legislature has a positive and statistically significant relationship on adoption time.



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