American federalism and contemporary health policy

This study explores the authority relationship between the federal government and the states and the impact of federalism on the development and implementation of contemporary health policy. The work provides insight into the role of federalism in the policy process. It identifies where and how policy decisions are made and how they might be influenced.;The primary research question is: how can the relationship between the federal government and the states be understood during the development and implementation of contemporary health policy? Two policy case studies are analyzed, the Health Insurance Portability and Accountability act of 1996 (HIPAA), and the State Children's Health Care Insurance Program of 1997 (SCHIP). Authority relationships are described as policy was developed in Congress, as rules were promulgated in federal administrative agencies, and as states implemented the programs.;Federal/state relations varied between the two cases and within each case based on the stage of policy development. For SCHIP, states influenced policy development, and federal officials increasingly dominated federal/state relations during the rulemaking process. Implementation was characterized by state specific negotiating over the application of national standards. For HIPAA, state authority over insurance regulations increased as rules were developed and policies were implemented.;Federalism is a dynamic political process, continually changing and subject to negotiation and manipulation. Policy maker's position on federal/state relations is not set, but contingent on policy preferences. Devolution of power from the federal government to the states is not happening in health policy. The federal government remains active, albeit more incremental and conservative. This said, states play a significant role in the construction and implementation of national health policy. Findings confirm an institutional bias against a strong national bureaucracy, and the powerful role of the states and the private sector in implementing policy. SCHIP demonstrates that even modest state success can lead to significant national health insurance coverage expansions. HIPAA demonstrates the difficulty both levels of government have in aggressively regulating a powerful industry.