Recipients of AcademyHealth’s Presidential Scholarship for the AcademyHealth Institute on Advocacy and Public Policy were invited to blog about their experiences during the 2013 National Health Policy Conference. The following post is written by Namrata Uberoi, a Ph.D. candidate at The Pennsylvania State University.  Political considerations at the national and federal level dominated the conversation in regards to the Affordable Care Act. However, shortly after the enactment of the ACA and the Supreme Court ruling, the focus turned over to the 50 states that were now in charge of implementing the regulations. Along with that came a whole new set of political considerations. The 2013 National Health Policy Conference’s special session: “Politics of Health Reform at the State Level” examined this dynamic political environment and focused on tensions at the state level regarding health reform. The panel was composed of experts from various backgrounds and states, some of which have decided to expand Medicaid under the ACA and some of which are not. The speakers included Joan Alker from the Georgetown University Health Policy Institute; Bruce Greenstein representing the Department of Health and Hospitals, Louisiana; Joshua Sharfstein from the Department of Health and Mental Hygiene, Maryland; and Michael Szubski from University Hospitals in Cleveland, Ohio. Each speaker emphasized different political considerations. Joan Alker focused on trends in Medicaid expansion. She emphasized the role of the Medicaid program and its federalist components. What she saw as the core component in Medicaid expansion was the ideological fight about the role of government and the interplay between federal and state regulations. Ms. Alker felt that if states do not decide to expand, then one of the most vulnerable populations would be left out in cold and consequently the ACA’s goal of universal coverage would not be met. Furthermore, her opinion was that the federal dollars offered to the states was “too good of an offer to turn down.” Nonetheless, states and the federal government will have some major issues ahead as ACA implementation continues. These include flexibility issues (i.e. partial expansion); benefits packages, which vary state-to-state; dealing with a new managed care population; cost-sharing rules; and premium assistance. Bruce Greenstein spoke about the overwhelming nature of the political dynamics of divided state branches. Greenstein believed the thing to watch for are the pressures from the state legislature to the governor or vice versa if the branches are politically divided. He also indicated that state governments may not be capable to meet the hurried deadlines and there was little synchronicity with state insurance regulations and those of the future exchanges. When asked why Louisiana was not establishing an exchange, Greenstein cited lack of flexibility, cost, and prevalence of private insurance in Louisiana as the key factors in that decision. In contrast to Greenstein’s experience in Louisiana, Joshua Sharfstein spoke about Maryland’s experience in preparing for the exchange. Mr. Sharfstein emphasized the “small p” politics (the “capital P” politics referred to the politics of political parties and their interactions with the president), which primarily involves getting state stakeholders together and understanding where all sides are coming from. Managing implementation at the state level encompasses hundreds of public and individual meetings all to make sure the end product is customizable within in each state. Sharfstein provided the determination of essential health benefits as an example of the politics at the state level. After a number of meetings, the state of Maryland had finalized a benefits package. However with the later release of federal regulations, a whole new public process ensued and the involved stakeholders went back to the drawing board and selected a different package. Finally, Michael Szubski speculated on Ohio’s decision to establish a federally facilitated exchange (an announcement that had come from Governor John Kasich (R) just the day prior). Szubski considered the discourse between the state legislature and the governor to be a major challenge as exchange implementation continued. Connectivity and the need to explain the value of expansion were cited as methods to persuade the legislature to get on board. States also need to be aware of the moving parts involved in ACA implementation, said Szubski. That is, people moving from uninsured to Medicaid, Medicaid to the exchange, private insurance to Medicaid, and private insurance to the exchange. Overall, the dynamic between the state executive branch (the governor) and the state legislature was cited by all the speakers as being the main challenge going forward – whether or not a state decided to expand or not. And I happen to agree. What I think will be most interesting is to see how states will continue to experiment in this arena. This is likely inevitable, given the ever-changing nature of state leadership and politics.