After a great deal of discussion and debate across all levels of government, President Obama signed the Affordable Care Act (ACA) into law in March 2010. Since President Trump's election into office, the ACA has stayed in the headlines. Trump has continued to call for the replacement and repeal of the ACA, and several efforts have spawned in both the House and the Senate to accomplish this goal. Unlike welfare reform, which was generally embraced by all states, the ACA has proven very divisive in some states, with some states actively seeking to block implementation. Alternative solutions continue to prove elusive. To better understand the major factors driving decision-making process and state-level dynamics influencing state support or opposition of the ACA, this book examines the initial implementation through established support and opposition factors across four states: Alabama, Michigan, California, and New Hampshire. The choices made by states are a direct consequence of long-term forces, and the choices made at the national level. State Politics and the Affordable Care Act will be of interest to scholars researching in public administration, policy formulation and implementation, and policy analysis.