Federalism in Health Care Reform

Holes in the Safety Net: Federalism and Poverty, 2019

24 Pages Posted: 1 Apr 2020

See all articles by Nicole Huberfeld

Nicole Huberfeld

Boston University - School of Public Health; Boston University School of Law

Date Written: August 1, 2019


This chapter explores the role of federalism in health reform focusing on the importance of universality in social programs. Protecting states’ rights within federal health reform laws throughout American history has served purposes other than the needs of the poor. This is revealed in the long history of excluding those deemed undeserving of assistance - the “able-bodied” - and this chapter traces the history of this terminology because it has reemerged in political discourse surrounding health care. Exclusion of those deemed "able-bodied" dates to Elizabethan England, was carried through to colonial, and later, state laws including the sale of enslaved people and Reconstruction era practices such as convict lease systems. This history provides context that should give current policymakers pause in revitalizing the concept.

The debates of the 20th century about the role of government in health and who is deserving of aid are bound to repeatedly arise without fully gauging federalism’s mixed effects in health reform. American federalism involves many separate state negotiations with the federal government, which leads to variability that can lower the baseline in reform-resistant states and thus across the nation as a whole. This is significant when the federal government attempts to improve conditions nationwide, as it did with the Affordable Care Act’s universal health insurance coverage. The example of Medicaid expansion under the ACA demonstrates how state variability can improve coverage but also jeopardize it. Federalism in health care can result in restricted access to the safety net, even when the federal goal is strengthening it.

Keywords: federalism, poverty, Medicaid, health reform, ACA, health care, health law, Obamacare

JEL Classification: I1, I10, I13, I14, I18, K32

Suggested Citation

Huberfeld, Nicole, Federalism in Health Care Reform (August 1, 2019). Holes in the Safety Net: Federalism and Poverty, 2019, Available at SSRN: https://ssrn.com/abstract=3341631

Nicole Huberfeld (Contact Author)

Boston University - School of Public Health ( email )

715 Albany Street
Boston, MA 02118
United States

Boston University School of Law ( email )

765 Commonwealth Avenue
Boston, MA 02215
United States

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