State implementation of the Patient Protection and Affordable Care Act has been uneven, at best. And while most states are playing along with the federal law, a study by the Commonwealth Fund that dropped late last week reveals some pretty stark differences at the state level.

The study breaks PPACA’s blueprint for expanded coverage into three broad categories, or what they call mechanisms: market reform implementation, establishment of exchanges and Medicaid expansion. And only a handful of states still aren’t playing ball — steadfastly refusing to implement any of the trio of reforms — and letting the feds run the marketplaces in their states.

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