The gress, in the courts, and in the states, due in extension of parental coverage to young adults, part to the far- reaching nature of the law. [. ] The Course of ACA Implementation We examine extant discussion of the implica- The Affordable Care Act is an extraordinarily tions of the ACA’s design for private insurance complex law with thousands of provisions, not markets and the major public insurance pro- to mention a politically contested one subject grams as well as the effects of the law on non- to unrelenting attacks by partisan opponent [. ] Subsequent articles in the variation permitted only on the basis of geog- issue—and the rest of our literature review—in raphy (market rating area, typically metropoli- turn examine the social, economic, and politi- tan statistical areas [MSAs] plus the remainder cal effects of many of the provisions that have of the state not included in an MSA), family been at least partly implemented. [. ] In a series of premium level above the median premium, and issue briefs, analysts at the Kaiser Family Foun- finds that vulnerable local markets are more dation have tracked the performance of insur- likely to be rural, to have less healthy popula- ers in the individual market since the passage tions, and to be in states that have not ex- of the ACA (see, for example, Cox, Levitt, and panded Medic [. ] They conclude that the ACA il- lustrates the “conceptual confusion” inherent effeCts of tHe ACA on Insur AnCe in American federalism: is “healthcare federal- Cover Age, ACCess to He AltH CAre, ism”—including the structural elements by And He AltH which the federal and state governments divide Unsurprisingly, dozens of studies estimate the responsibility—meant to produce “particular impact of the A