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The JAMA Forum
September 24, 2019

Federalism as an Antidote to Polarization Over Health Care Policy

Author Affiliations
  • 1Senior fellow, Economic Studies, at the Brookings Institution in Washington, DC
JAMA. 2019;322(12):1131-1132. doi:10.1001/jama.2019.14114

It is easy to be pessimistic about the future of health care policy, given the increasing polarization in Congress and in the country. We seem to be condemned to a future mix of gridlock, with occasional winner-takes-all lurches in one direction or another.

Federalism, however, is a powerful tool for helping to resolve such standoffs in the United States. The states’ role as “laboratories of democracies” has long been appreciated as an important technical feature of federalism. It is important also to recognize federalism’s powerful political role in resolving impasses, and its potential for doing so in health care.

In addition to creating consensus among warring political factions, federalism has often been decisive in helping to achieve reform. For instance, the then-controversial women’s suffrage campaign gained power in a tidal wave from Western states, as state after state granted the vote, eventually shifting the balance toward congressional passage of a constitutional amendment. And it is important to recall that the Supreme Court’s 2015 same-sex marriage decision encountered almost no resistance, because in the decade leading up to the decision, dozens of states legalized same-sex unions and marriages.