A preliminary observation about implementation of the ACA: it differs significantly from earlier episodes of Medicaid or Medicare implementation. In earlier cases, implementation was mostly “rule-making”—aimed at translating legislative texts into rules and guidances and leaving it up to the states and health care providers to operationalize these directives, with some federal technical assistance, templates, and data files, backed by various sanctions and inducements. Implementation of the ACA involves rule-making of this sort, but with much more emphasis upon system design and development, such as high-risk insurance pools, consumer information networks, and the all-important health insurance exchanges.