ABSTRACT
From a state perspective, the major Affordable Care Act (ACA) implementation challenges are the Medicaid eligibility and enrollment amendments, followed by the payment and delivery system reforms. How and by whom the health insurance exchanges are organized is important for the overall working of the ACA in eligibility determination and enrollment, as well as for quality and risk management. Managed care was extended to additional population groups and areas, and five states sought waivers to develop comprehensive plans. Medicaid is the primary payer for Long-Term Services and Supports, accounting for half of the total national expenditures_federal and state-so that these expenses were a prime target for the ACA. Federal innovation efforts under ACA focused first on Medicare. The state innovation model initiative, first announced in July 2012, was notable for the attention devoted to the process of innovation within the states and by its effort-of seeking to foster and strengthen a culture of innovation.
