American Federalism and Healthcare

Introduction

The authors of the U. S. Constitution based their ideas of America on the principles of unity and individual independence. Though they never used the term “federation,” the United States is a classic federative structure. The principle of separation of power is among the main decisive elements of the Constitution aimed to ensure its stability while remaining flexible. However, though individual states are supposed to have broad legislative authority on their territories, some areas of law are still primarily controlled by the federal government, including healthcare. While some scholars criticize the current American federalism for such contingencies, others praise the national legislative system for things like the Patient Protection and Affordable Care Act (ACA). This paper aims to uncover the ideas and principles of American federalism in comparison with the separation of power and the context of contemporary healthcare, including the ACA and its influence on the daily life of regular citizens.

Discussion

Federalism and the Separation of Powers

American federalism has arisen as an optimal system for separation of legislative and executive powers between the federal and state governments. Federalism is regarded as beneficial for democratic systems precisely due to its power separation (Grumbach & Michener, 2022). Section 1 of the Constitution assigns legislative power, to the Congress, while other sections define the independence of the executive and judicial branches under the President and the Supreme court (U.S. Const. Art. I, §1; U.S. Const. Art. II, §1; U.S. Const. Art. III, §1). For healthcare, while the federal government is responsible for regulating interstate commerce, taxation, and general welfare spending, the states can regulate general welfare activities inside their jurisdiction. The majority of federal health care programs are developed by the Department of Health and Human Services, while the implementation of these programs is delegated to the state governments.

Federalism and Healthcare Laws

While national political polarization can hinder the development and adoption of federal healthcare programs, the states actively pass new cost and quality legislation. In 2019, state governors emphasized healthcare issues, including Medicaid expansion, workforce outflow, and associated costs (Murray et al., 2019). Federalization allowed the states to influence these issues through price transparency, benefit design, provider payment, provider networks, and market power laws. Under the ACA, federal funding is combined with states’ responsibility for implementation, separating legislative and executive powers. However, the existing legal doctrine does not comprehend the blended nature of statutes like the ACA (Gluck & Huberfeld, 2018). It has shown that Congress mostly makes centralized decisions in healthcare. At the same time, the states are limited in their healthcare legislative capabilities to local policies and healthcare activities.

The Impact of Federalism on Healthcare in Practice

The ACA implementation policies differ significantly from state to state. For example, Rhode Island insurers experience strict state regulations, while in most other states, the insurance rates are determined solely by the providers (Murray et al., 2019). The primary purpose of the ACA to reduce the number of uninsured citizens was partially achieved by allowing the states to implement the Act through local healthcare legislation (Chait & Glied, 2018; Zhao et al., 2020). The Act obliged health insurance companies to price premiums based on family size, age, geographic area, and tobacco use, excluding sex, occupation, and medical history from the insurance pricing factors. It has helped to protect regular Americans from vulnerable groups, including cancer patients and survivors, from being excluded from insurinance premiums due to job- and health-related risk factors. According to Goelzhauser and Konisky (2020), the number of uninsured Americans has decreased almost two times since before the ACA’s enactment.

However, tensions sometimes arise between the federal and state governments, evident in the federal strategy to delegate the COVID-19 epidemic response entirely to the states. When states declared emergency, the federal administration refused to distribute medical supplies, simultaneously urging states to open their economies (Kincaid & Leckrone, 2022). While states had to compete between themselves and the federal government, regular citizens suffered a lack of protective measures. The federal restriction of travel from China and the enactment of a USD 8.3 billion emergency aid were among the most significant federal decisions (Kincaid & Leckrone, 2022). Nevertheless, the bi-party form of the American federalism allowed for a broad range of response policies like state-wide stay-at-home orders. Those helped mitigated the worst prospects but still suffered from a lack of cooperative response (Kincaid & Leckrone, 2022). The federal government’s role in funding the development and distribution of vaccines was a vital part of fighting the epidemic. These examples, however, demonstrate the controversial nature of American federalism, which inevitably affects healthcare.

Conclusion

American federalism is an exemplary case of the successful separation of powers providing equal possibilities for state and federal governments in legislation and implementation of laws and regulations, particularly in healthcare. A notable case of a successfully designed and effectively implemented healthcare policy is the Patient Protection and Affordable Care Act, aimed at reducing the number of uninsured Americans and improving public health quality. While states have used different approaches to implementing the Act, its effects are noticeable in drastically reducing the number of uninsured citizens. While federalized healthcare provides a degree of autonomy to individual states, in practice, it often generates tensions due to interstate and federal-state competitiveness. Critical situations like the COVID-19 pandemic can challenge the system by elevating the existing issues of unequal resource distribution. While some scholars argue for a more centralized and rigid healthcare structure, others vow for further federalization giving individual states and private providers stronger positions in healthcare legislation and authority over budget spending. Therefore, the relevance of contemporary American federalism and its role in healthcare remains open for discussion.

References

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Gluck, A. R., & Huberfeld, N. (2018). What is federalism in healthcare for? Stanford Law Review, 70, 1689–1803. Web.

Goelzhauser, G., & Konisky, D. M. (2020). The state of American federalism 2019–2020: Polarized and punitive intergovernmental relations. Publius: The Journal of Federalism, 50(3), 1–33. Web.

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Huberfeld, N. (2019). Epilogue: Health care, federalism, and democratic values. American Journal of Law & Medicine, 45(2-3), 99–294. Web.

Kincaid, J. K., & Leckrone, J. W. (2022). American federalism and COVID-19. Party Trumps policy. In N. Steytler (Ed.), Comparative federalism and COVID-19 (pp. 181–199). Routledge.

Murray, R., King, J. S., Delbanco, S. F., & Lehan, M. (2019). The state of state legislation addressing health care costs and quality. Health Affairs Blog. Web.

U.S. Const. Art. I, §1

U.S. Const. Art. II, §1

U.S. Const. Art. III, §1

Zhao, J., Mao, Z., Fedewa, S. A., Nogueira, L., Yabroff, K. R., Jemal, A., & Han, X. (2020). The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years. CA: A Cancer Journal for Clinicians. Web.