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March 16, 1994

Getting a Head StartThe States and Health Care Reform

JAMA. 1994;271(11):875-878. doi:10.1001/jama.1994.03510350087045
Abstract

SEVERAL years ago, Bruce Vladeck, PhD, who is now the administrator of the Health Care Financing Agency, pointed out that health policy "is the last great unsettled area of federal-state relations." Although he was referring to intergovernmental quarrels over Medicaid, his remark also foreshadowed the growing tension over which responsibilities (fiscal and otherwise) will be federal and which will fall to the states as health care reform takes shape.

Former New York Congressman Otis Pike years ago observed that no city will undertake to pay for any activity it thinks it can get the state to pay for, and no state will undertake to pay for any activity it thinks it can get the federal government to pay for. The Medicaid program, passed by Congress in 1965, is a classic example of shared turf and its problems. Funded jointly by states and the federal government, administered by states but regulated

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