Context: This article argues that the devolution of the Affordable Care Act (ACA) to the states contributed to the slow progression of national public support for health care reform.

Methods: Using small-area estimation techniques, the authors measured quarterly state ACA attitudes on five topics from 2009 to the start of the 2016 presidential election.

Findings: Public support for the ACA increased after gubernatorial announcement of state-based exchanges. However, the adoption of federal or partnership marketplaces had virtually no effect on public opinion of the ACA and, in some cases, even decreased positive perceptions.

Conclusions: The authors' analyses point to the complexities in mass preferences toward the ACA and policy feedback more generally. The slow movement of national ACA support was due partly to state-level variations in policy making. The findings suggest that, as time progresses, attitudes in Republican-leaning states with state-based marketplaces will become more positive toward the ACA, presumably as residents begin to experience the positive effects of the law. More broadly, this work highlights the importance of looking at state-level variations in opinions and policies.

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