This report is part of a series of 21 state and regional studies examining the rollout of the ACA. The national network -- with 36 states and 61 researchers -- is led by the Rockefeller Institute of Government, the public policy research arm of the State University of New York, the Brookings Institution, and the Fels Institute of Government at the University of Pennsylvania.
There is clear alignment among most groups and institutions on the state's adoption and implementation of the ACA. Because of its all-payer rate system, competition between private plans and exchange plans is muted. Some conservative elements in the Democratic-heavy legislature oppose rate-setting and the state's generous Medicaid expansions as well as its affirmation of the ACA. But with strong Democratic majorities in both houses, together with Democrats in the governor's and lieutenant governor's offices and professionals with policy and political expertise, the state's progressive reformers are clear winners. The state's inclusive and generous eligibility decisions will afford coverage to a broad portion of the state's uninsured populations. Advocates for these groups also win. In the case of Maryland, the "stars were aligned" to formulate an aggressive and expansive approach to the law. Minority opposition simply could not mount effective challenges to these forces.