Title

Epilogue: Health Care, Federalism, and Democratic Values

Document Type

Article

Publication Date

5-2019

ISSN

0098-8588

Publisher

American Society of Law, Medicine & Ethics

Language

en-US

Abstract

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.

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