Education---state vs federal debates are good, based in the literature, and critical to refining healthcare advocacy

There are literally thousands of articles and several journals on various aspects of federalism. Yet health policy scholars have put remarkably little effort into developing criteria to assess the comparative advantages of state versus federal dominance.1 If the usual American approach is deference to states, then one might argue that the default option for policy making in health care ought to be state-level reforms. If the states are unable to arrive at satisfactory solutions, then responsibility should shift to the federal government. In either event, it would be helpful to have some agreed-on criteria for when federal intervention would be appropriate.

In this article, we set forth and analyze a set of normative criteria for determining whether states or the federal government should more appropriately lead in health care reform. They should help move the debate beyond opportunism or overly broad arguments for state or federal leadership. We develop our criteria by comparing the ability of the federal government and the states to live up to certain desirable values: social justice, procedural democracy, compatibility with value pluralism, feasibility, and economic sustainability. The next section argues that leadership is the right framing because no level of government can effectively act alone on major issues, but in an interpenetrated intergovernmental system one level needs to lead (see also Mechanic 2003 and Sparer 2003). We then expand on the criteria and their implications for health reform policy.

Our conclusion is that the benefits of states’ leadership lie mostly in values issues, where their economic disadvantages are less acute. For health reform, the criteria suggest that a strong federal role is imperative to overcome the states’ limitations in financing redistributive programs, such as coverage expansions, and in protecting rights. In contrast to current policy and reform proposals, which have a tendency to consider values at the federal level and shift coverage responsibility to the states, we argue that the states ultimately lack the capacity to enact and implement major health coverage and financing reforms but can lead in areas such as end-of-life care laws or drug laws.

In reaching this conclusion, we certainly recognize that the distressing litany of historical failure at both the state and federal levels provides no guidance in answering the question of federalism in health care reform. Our purpose is not necessarily to resolve the debate as much as it is to offer a set of criteria for discussing the comparative advantages of state versus federal leadership. Nor is our goal to discourage activists from using whatever strategies put their issues on the agenda. Rather, it is to point out that we can have criteria for good policy and that these criteria have a role in public debate because they help steer it away from unrealistic expectations.