American Federalism in Practice

American Federalism in Practice: The Formulation and Implementation of Contemporary Health Policy

Michael Doonan
Copyright Date: 2013
Pages: 160
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  • Book Info
    American Federalism in Practice
    Book Description:

    American Federalism in Practiceis a major contribution to our understanding of contemporary health policy in America. Always an important topic, the issue holds special currency today given the prominence of health care in today's political and economic landscape. Michael Doonan provides a unique perspective on American federalism and U.S. health policy in explaining how intergovernmental relations shape public policy in health as well as other critical areas.

    Doonan tracks federal-state relations through the creation, formulation, and implementation of three of the most important health policy initiatives since the Great Society: the Children's Health Insurance Program (CHIP) and the Health Insurance Portability and Accountability Act (HIPAA), both developed in Congress, and the Massachusetts health care reform program as it was developed and implemented under federal government waiver authority. Massachusetts, though not without having to face challenges, actually succeeded in lowering its uninsured rate to below two percent.

    Success and failure of these three programs can be traced in large part to a balance between state flexibility and accountability to meet program goals. Achieving that balance is not easy, of course, but lessons learned from previous successes-and failures-in structuring intergovernmental relations offer unique insights into national health reform and contemporary public policy.

    Doonan reveals how federalism can shift as the sausage of public policy is made, providing a previously missing link between federalism theory and practice. His work should change the way people think about federalism in a policy context while providing a new and useful framework through which we can view, and hopefully comprehend, some of the most important and polarizing policy debates of our time.

    eISBN: 978-0-8157-2484-1
    Subjects: Health Sciences, Political Science

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-vi)
  3. Acknowledgments
    (pp. vii-viii)
  4. CHAPTER ONE Federalism Creates Health Policy
    (pp. 1-15)

    Friends in my small town know that I have been involved in national health care reform efforts as well as those in our home state of Massachusetts. When conversation at the local pub turns to health care, they’ll ask me questions. Because I’m a political scientist, not a medical doctor, I don’t get pelted with questions everywhere I go, so I welcome the opportunity to respond. I only wish that there were better answers.

    Jack, a salesman for a high-tech company, thought that the Massachusetts health care reform would allow him to cover his 24-year-old daughter, Meghan, on his employer’s...

  5. CHAPTER TWO CHIP: Federalism in Congress
    (pp. 16-29)

    The State Children’s Health Insurance Program of 1997 (CHIP) was enacted during an especially turbulent time in American politics. The Clinton health care plan had failed, and conservative members of Congress were emboldened to make some big moves. Under the leadership of Speaker of the House Newt Gingrich, Republicans passed a plan to end the federal entitlement to Medicaid and replace it with block grants to the states. In a showdown with Congress, President Clinton vetoed the bill, shut down the government, and eventually saved the program. Incredibly, that was the environment that gave birth to what was at the...

  6. CHAPTER THREE CHIP: Federalism and Rulemaking
    (pp. 30-42)

    Laws passed by Congress do not emerge as finished products. Before they can be fully implemented, they have to go through the underappreciated but crucially important process of administrative rulemaking. This phase defines how a law will work in the real world, thereby creating policy. Rulemaking is nearly as important as the legislative process, but it is often ignored. It’s not as sexy as the podium-pounding, headline-grabbing battles that can take place in Congress. It is not easy to understand, and it is often relegated to the domain of wonks, insiders, and lawyers. From personal experience I can attest that...

  7. CHAPTER FOUR CHIP: Federalism and Implementation
    (pp. 43-56)

    Implementation is where the rubber hits the road, where abstract policies and rules have real impacts on people, where intergovernmental relations are solidified in practice. As a process, implementation turns out to be every bit as political as rulemaking. Analysis of CHIP implementation reveals that in a collaborative effort to make the program work, broader national safeguards remained even as states regained some autonomy. The federal government negotiated directly with different states, which led to variations throughout the country. Despite some inconsistencies, CHIP accomplished its main goals: to provide public health insurance to eligible children and to reduce the disparities...

  8. CHAPTER FIVE HIPAA: Federalism in Congress
    (pp. 57-70)

    When I tell my graduate students, “Today we will be talking about something truly fascinating [dramatic pause]: health insurance regulation,” the line never fails to elicit groans. The truth is that health insurance can be intriguing—except for the parts that are bone dry. But grasping the complexity of the issue is essential to understanding how the U.S. health care system works and how it might be shaped by national reform.

    The Health Insurance Portability and Accountability Act (HIPAA) of 1996—an act that passed in the wake of failed national reform at a time when conservatives controlled Congress—is...

  9. CHAPTER SIX HIPAA: Federalism and Rulemaking
    (pp. 71-83)

    The rulemaking process that turned HIPAA legislation into policy should serve as a cautionary tale for national reform through the Patient Protection and Affordable Care Act. The HIPAA rule used the threat of a federal takeover of a state regulatory function to enforce the insurance portability provisions. However, because the federal government did not have the resources, staff, expertise, or desire to back up the threat, it capitulated to the states during the rulemaking process, thereby weakening the law. Similarly, if the states refuse to create health care exchanges under the ACA, the only recourse is for the federal government...

  10. CHAPTER SEVEN HIPAA: Federalism and Implementation
    (pp. 84-98)

    As HIPAA became the law of the land, the federal government continued to defer to the states in important ways. Because of passive federal oversight, states took control of the scope and shape of insurance reforms, particularly in the individual market. In contrast to the implementation of the CHIP rule, which resulted in greater uniformity between states, implementation of HIPAA maintained the diversity that already existed among the states. Oversight was so weak that states could basically enact what they wanted, when they wanted. As a result, HIPAA largely failed to make insurance more available and affordable.¹ Implementation of the...

  11. CHAPTER EIGHT Massachusetts Leads the Way
    (pp. 99-114)

    Today, the suggestion that a Republican administration had anything to do with Massachusetts health care reform would be more shocking to folks on the right than the left. After President Obama used Massachusetts as a model for national reform, Republican and Tea Party activists started to take a much dimmer view of the scene in Massachusetts. Though George W. Bush did not exactly highlight the fact in his memoir, his administration led the way to reform in Massachusetts by pressuring the state to overhaul its health care system in 2005. Further, the administration explicitly approved key components of the plan...

  12. CHAPTER NINE Federalism and the Affordable Care Act
    (pp. 115-130)

    Beginning with President Franklin D. Roosevelt’s New Deal in the 1930s, Americans began to look to the federal government to remedy some of the country’s most pressing social, economic, and environmental ills. The Social Security Act of 1935 created federal pensions, unemployment insurance, and welfare assistance programs. In the 1960s, President Lyndon B. Johnson’s War on Poverty and other Great Society–era programs significantly expanded the role and reach of the federal government. Social Security was broadened, welfare assistance expanded, and Medicare and Medicaid were created. Strong environmental standards and regulations were passed, including the Clean Air Act and the...

  13. Notes
    (pp. 131-152)
  14. Index
    (pp. 153-159)
  15. Back Matter
    (pp. 160-160)