Health Care Policy Making in the Federal System

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1 April 2016

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Patient Protection and Affordable Health Care Act

Open policymaking in the United States is molded on a basic level by American federalism. Federalism in the United States is defined as “a governmental system whereby power and authority are shared by national and state governments, with ultimate authority derived from the people” (Levin-Waldman, 2012). The interaction between the levels makes a muddled approach process. Government policymakers and bureaucrats at diverse levels of the elected framework – national, state and local – regularly have truly distinctive interests and points of view on how specific policies ought to be developed and implemented.

In regards to health care policy, the national government has accepted essential obligation, with states playing a significant but auxiliary role. For national and state policymakers, there are three key objectives in healthcare policy: control services expenses of health care, improve the quality of health care, and allow for all citizens to have access to health care. The challenge is to beat the long-standing status of the U.S. as a nation with high medical costs paired with deficient coverage for a number of its citizens.

On March 23, 2010, after a multitude of debates and votes, Congress approved and President Obama signed into law the Patient Protection and Affordable Health Care Act ( This is the most comprehensive health care law passed at the national level, and possibly the most controversial too. This enactment is giving a real test of American federalism. Each state is required to create an exchange in which people can look for a competitive plan. This online exchange will offer individual people, families, and small businesses a venue in which to review suitable and affordable plans. In the event that a state does not make an exchange, the national government will do so.

There are many debates surrounding this new law as many feel it will do more harm than good. Under the law, tens of millions of uninsured will get access to competitive, quality, health insurance. In order to help cover the many millions who require monetary assistance, there are new taxes, generally felt by the upper income levels. These taxes are in the form of mandates; either as an individual mandate or an employer mandate. These mandates require individuals to obtain coverage, get an exemption, or pay a fee.

However, it is estimated that over half of those uninsured prior to this new law, will be able to obtain free or low cost coverage thru their State’s exchange. Similarly, employers with an equivalent of 50 full time employees must provide health insurance coverage to their employees or they will have to pay a fine. This has prompted some businesses to cut employee hours to avoid meeting the criteria, although small businesses can qualify for up to 50% of their employees premium costs. (

While the law allows young adults to remain on their parents plans until the age of 26, there is concern that the premiums these young adults could be paying on their own would help offset the rise in premiums due to the sick. In order for the premiums to remain low, there needs to be a significantly large healthy pool of insured. Their premiums will offset the expenses the insurance company will have to pay for the claims of those that are sick. If healthy young adults remain on their parent’s plans longer, it decreases the cushion the insurance company has to cover such claims. Since you cannot be dropped from your plan when you become sick, insurance companies must cover the sick and this causes premiums to rise. (

Many question whether or not the government can enforce such a law. The U.S. Constitution makes no reference to health care policy or services as rights. To play a role in such, the national government must turn to less particular parts of the Constitution, for example, the obligation to “promote the general welfare,” provide “equal protection under the laws,” or “regulate commerce among the states.” State constitutions by and large make no particular reference to health awareness as a commitment of state government or right of residents.

Likewise with the national government, state power around there rests principally on more general protected provisions to promote the benefit of everyone. The law was presented to the Supreme Court and upheld by a vote of 5 to 4. “The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax,” Chief Justice Roberts wrote in the majority opinion. “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.” (


Policymaking in our federal system is laden with challenges. In health care, policymakers and other government authorities at all three levels of government assume vital and interconnected parts. Policymaking in our federal system has served the United States well for a long time, yet it remains a real test. It is uncommon that one level of government can bring an approach through to its fulfillment. Rather, most arrangements incorporate an imperative intergovernmental element.

The unpredictability of intergovernmental policymaking and the numerous purposes of potential restriction in an elected framework put a premium on practicing successful initiative and making intergovernmental connections. To push ahead in the 21st Century, national, state and local policymakers will require a full set of administration and interpersonal abilities to unite all parties in the federalism process of policy making.


Levin-Waldman, O. M. (2012). American government. San Diego, CA: Bridgepoint Education, Inc.
Liptak, A. (2012, June 28). Supreme Court Upholds Health Care Law, 5-4, in Victory for Obama. The New York Times. Retrieved from
Is the Patient Protection and Affordable Care Act (Obamacare) Good for America? (2010, September). Retrieved from The Pros and Cons of Obamacare. (n.d.). Retrieved from

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