《可负担的医疗法案》是在美国两党政治对立的情况下颁布和实施的。本文认为,美国联邦和州政府角色权限的分配,加剧了该法案执行过程中的政治冲突。联邦和州层面的政治参与者(特别是州长和州立法机构)就该法案进行制度协调的不同途径,已经阻碍了医疗保险交易所的建立和医疗救助扩展计划。通过比较,本文认为制度设计时尽量减少政治冲突的医疗保险监管机制改革,在执行过程中大幅度减少了政治摩擦。此外,本文强调了多层次制度设计对实施一些重要改革所产生的政治影响。 The Affordable Care Act was promulgated and implemented in the context of bipartisan political opposition in the United States. This paper argues that the distribution of the role of the federal and state governments in the United States exacerbates the political conflict in the implementation of the Act. Different approaches to institutional harmonization of the Act by federal and state political players, notably governors and state legislatures, have hampered the establishment of health insurance exchanges and the expansion of medical assistance. By comparison, this paper argues that the reform of the medical insurance regulatory mechanism that minimizes the political conflicts during the design of the system drastically reduces the political friction in the process of implementation. In addition, the article emphasizes the political impact of designing a multi-level system on the implementation of some important reforms.