Objective The passage of the Affordable Care Act of 2010 has been one of the most hotly debated policy issues in recent memory. Southern state politicians seem particularly opposed to the law, but data suggest that citizens of southern states would benefit from the law. This article explores the choices made by states in terms of their acceptance and implementation of the Patient Protection and Affordable Healthcare Act (PPACA). Methods Employing standard explanators of state policy choices, coupled with common indicators of public health, we examine a cross‐sectional, 50‐state regression model to determine whether southern states are different from other states in their policy choices in this arena. Results We find that southern state choices are driven by control of the governor's mansion, while other factors drive non‐South state choices. Conclusion Our findings lend support to the notion of southern distinctiveness—southern states are driven more by politics, while non‐South states are driven more by state circumstances.