ABSTRACT
This chapter examines the early implementation of the ACA in Alabama. Alabama is a state that opposed the ACA in every way possible, yet our case study reveals that the decision to oppose the ACA was not as clear-cut as it might appear. There were factions in the state that were in favor of the ACA, and early discussions included both the creation and operation of states exchanges and Medicaid expansion. In spite of a significant need in the population for greater access to health care, Alabama ultimately rejected the ACA by defaulting to the federal exchange, refusing to expand Medicaid, and joining the federal lawsuit to block implementation of the ACA. We conclude that Alabama policymakers were constrained in their actions by a combination of state political history, state political culture, a flawed private insurance market, and a political system that divides political power and influence into many different elected offices.
