Debates over health care reform often focus on the appropriate role for the government in health care. Much less attention is paid to defining the respective roles of the states and the federal government. Yet, in the American political system, the basic issue of federalism has profound implications.

The question for the nation is which aspects of health policy should reflect national, uniform standards, and which should vary according to local conditions, values, and preferences. Economic mobility and the desire for efficiency militate for national uniformity and federal standards. By contrast, state policies can be more closely tailored to local economic conditions and can reflect local values regarding matters such as the appropriate role of government.