This chapter examines the four key insights from the case study states, looking at the degree to which these lessons apply elsewhere. I ask what the Obama administration should have done differently in its intergovernmental negotiations with states and whether the decision to accept or reject control of an exchange matters. In other words, what are the policy implications of this decision? A Supreme Court case in 2015 would have dramatically raised the stakes of this decision, though the Court’s ruling in favor of the Obama administration ensures that any person with a qualifying income can receive financial assistance to purchase coverage on an exchange—regardless of their state’s decision. I conclude by examining the future of health insurances in particular, and health reform and U.S. federalism more broadly.
The Supreme Court and Health Reform