Initial state implementation of the Affordable Care Act health exchanges was marked by political polarization. More than half of the states initially chose not to create their own health exchanges, leading the federal government to adopt a new strategy: dividing the implementation of health exchanges into a series of smaller tasks. States could choose which of four core functions of the exchanges they would implement, with the federal government handling the remaining functions. This strategy induced some resistant states to administer some core functions. Why did some states take part in the exchanges while others did not? Ordered logistic regression analyses provide evidence that both state political context and other factors affected this decision. The analyses also suggest that state officials considered state workforce capacity and financial inducements from the federal government and that they were influenced by divided government.
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