Intergovernmentalization of Health Care Reform: The Limits of the Devolution Revolution

Though the states appear to be the focal points for reform of the health care delivery system, the national government is setting the limits within which they must operate. This is occurring despite the general opposition to national involvement by states’ rights advocates, insurance companies, health maintenance organizations, pharmaceutical companies, small business interests, and some segments of corporate America. National constraints on state initiatives are a function of two conditions. First, expanded participation in federally funded programs, especially Medicare and Medicaid, has broadened the pool of those eligible for coverage. Second, care providers—that is, medical practitioners and hospitals—often prefer national regulations to state guidelines or no governmental rules at all. The support for national regulations increasingly has led to the unusual situation in which the care providers and the populations they serve often share a common interest in maintaining a regulatory framework within which state programming changes/reforms occur.