Document Type


Publication Date





Boston University School of Law




Is the United States experiencing a “crisis of democracy in health care”? This symposium's central question can only begin to be addressed here. The answer depends, in part, on where we look and how we measure democracy.

Democracy is a complex ideal often said to be promoted by federalism. In health care, each level of government exercises power because federalism is a default choice in health reform efforts. This default enables state governments and the federal government to create, enforce, and adjudicate health law and policy - democratic operations at the national and the subnational levels. But on each democratic dimension – sovereignty and accountability – evidence of compression and expansion exists.

This essay briefly studies the assertion that federalism is a structure that advances the democratic values of sovereignty and accountability by considering the two key federalism-based features of Patient Protection and Affordable Care Act (“ACA”) implementation. Through the lens of these reforms, we see that the question of whether democracy is in crisis is even more complex than we might expect.

Link to Publisher Site Link to Publisher Site (BU Community Subscription)



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.