Why is healthcare in the US viewed by many as a federal issue, instead of a state issue? It seems to me, it would make more sense to implement healthcare reform on a state level, like they did in Massachusetts.

  • 9
    As I understood it's widely viewed as a state issue by Republicans, and widely viewed as a human right issue by Democrats. Commented Apr 3, 2019 at 8:52
  • 1
    I don't agree that the premise of this question is correct. Both state and federal governments currently, historically and going forward have a large role in different aspects of health care policy.
    – ohwilleke
    Commented Apr 5, 2019 at 0:07

3 Answers 3


There are a couple of reasons.

Lots of things are seen as federal issues by some people and healthcare just happens to be one of them

The sort of federalism where there is a small federal government focused on a small set of responsibilities, with state governments that can focus on nearly anything else that they want, is not popular with everyone in the United States at the moment. There are many reasons for that, but they all tend to stem from a belief that government should be doing something it isn’t presently, and that the federal government is uniquely powerful, so it should use its unique power to do whatever it is that should be done.

Healthcare is really expensive, so it’s hard for states to pay for it

You cite Massachusetts as a state that implemented healthcare reform, and it is a good example. However, the current appetite for reform that some people have involves something vastly more complicated than a mandate to purchase health insurance; the current idea in vogue is a single payer healthcare system.

Single payer healthcare provided at the sort of standard Americans are used to receiving is really, really expensive. So much so that Vermont and California have both abandoned proposals to implement a statewide form of it over fiscal concerns. This doesn’t stop people from wanting it, so the natural entity to try it is the Federal government, which has several unique advantages that states don’t have:

  • The Federal government has a very large tax base compared to any one state
  • The Federal government can borrow money at really low rates compared to state governments
  • The Federal government can (indirectly) control the supply of money to make paying for all of this easier (this would be a bad thing but there’s a new intellectual fad centered around this idea).

None of these things mean that single payer healthcare is more likely to succeed at being implemented, or be a success when implemented, but the federal government can hypothetically get any such scheme over all of the hurdles that states have already run into. Whether that would be desirable or not is an exercise I leave for the reader.

  • Re "fad": which fad? A cite URL would be useful. Also, a link to economies of scale, or some similar concept, might fit the answer's main idea.
    – agc
    Commented Apr 3, 2019 at 16:04
  • 3
    @agc So called "Modern Monetary Theory". I would have to take time to find a good citation for it; the wikipedia page is currently full of issues re: original research. Also, the question is specifically about why the Federal government is attractive compared to others. The motivating factor isn't economies of scale, which requires no government power of any kind at all, but that the federal government can print money, which state governments cannot do.
    – Joe
    Commented Apr 3, 2019 at 16:29
  • 1
    what is different in the health care system "being wanted" in the states to health care systems in place in Europe that makes it so much harder to finance on a state level - with several states having about the same GDP as European countries? Or is state taxation simply so much lower than federal taxation? Commented Apr 4, 2019 at 0:49
  • 1
    @FrankHopkins The bill “without a concrete funding plan” was estimated to cost $400 billon. Total California state spending this year is approximately $200 billion. There is no popular movement that is going to find double the current state spending in a state that already has significant problems in managing its debt and high taxes.
    – Joe
    Commented Apr 4, 2019 at 3:35
  • 3
    @FrankHopkins and to answer your first question, yes, state taxes are typically lower than federal taxes. More importantly, they are both much lower than European taxes. Your average American can not comprehend the idea of a 40% tax bracket applying to someone who makes the average wage, but this is totally common in most of Europe.
    – Joe
    Commented Apr 4, 2019 at 3:40

Because the federal government spends a substantial portion of the healthcare dollars. It's noteworthy that the United States government (federal and state combined) spends more money on healthcare than the United Kingdom's government. There are basically four federal programs:

  • Veterans' Affairs. For military veterans. Funded entirely by the federal government.
  • Medicare. For people 65 and older. Funded entirely by the federal government. Possibly with copays.
  • Employer. For federal employees. The insurance is funded entirely by the federal government but can include copays and deductibles. The federal government employs one sixth of all US workers.
  • Medicaid. For those with low incomes. At least 50% funded by the federal government, with the remainder financed by state governments. Can include copays and deductibles.

When Massachusetts passed its healthcare reform, it had to get waivers from the federal government. Medicaid had requirements for who was eligible and for what that weren't met by Romneycare. It was able to get these waivers because the legislators were Democrats and the governor (Mitt Romney) was a Republican. So there was a bipartisan request to the federal government.

To make a serious reform at the state level, the state would have to get federal approval for waivers. Since the current set of proposed reforms is only supported by Democrats, they are unlikely to get federal approval for the necessary waivers to take over VA hospitals, Medicare, the insurance of the federal employer, and Medicaid. There are actually some proposals by Republicans that might help, but Democrats are ideologically opposed to things like block granting Medicaid or privatizing the VA and Medicare.

Another problem is taxes. If Vermont, California, or New York passed single payer healthcare, then they'd have to fund it with state taxes (because states can't deficit spend). Because rich people can move more easily than poorer people, those taxes would mostly have to be raised on the middle class or employers of the middle class. And of course if they raise taxes on employers, it is possible that the employers might leave.

Another way of saying this is that state governments have found it impossible to fund single payer. So supporters hope that the federal government will be able to do so. This seems unlikely. While the federal government can borrow money, it's already at its limits for a non-recession economy. The only time that the US had a higher debt to GDP ratio was after World War II and the Great Depression. Wikipedia

I also remain unconvinced that increasing tax rates on the rich will increase tax revenues in the long term. The rich have far more options for collecting their income than the middle class do. So they are likely to do so even in the face of high taxes. Either by hiding their income in lower taxed income types (e.g. capital gains) or by hiding their income in lower tax jurisdictions (e.g. Caribbean island countries).

It's also noteworthy that even with static scoring (assuming no income hiding), the two main proposals, a wealth tax and a 70% income tax rate on incomes over $1 million, only produce $345 billion in revenue a year combined. That's well under half the current budget deficit much less the costs of single-payer. And as I said, I suspect that in reality the loss in taxes from increased evasion would entirely offset any gains. While other countries do have higher revenues per person, they do this not from higher taxes on the rich (the US has the highest percentage of its tax revenue paid by the rich among OECD countries), but through higher taxes on the middle class.

Politicians in the US have been talking about single payer health care for decades. I witnessed it first hand in 1992. Polls will even show it as popular until the costs are included. But people who have employer-based health insurance don't want to give it up. Most employers don't want to replace buying insurance with a tax. Most employees don't want to replace insurance that their employer buys with a tax that they pay. And most doctors and nurses don't want to take the pay cuts from single payer.

All those problems apply to states as much as the federal government. Or more than. It's much easier to migrate from a state than a country. And the long term fixes (e.g. free education for doctors and nurses) are, well, long term and not much help in the near term.

  • 4
    While the first half of this shows a good argument for it being a federal issue vs the states, the latter part is more of an opinion against tax increases and single-payer in general.
    – Geobits
    Commented Apr 3, 2019 at 18:38

One additional argument I have heard from single-payer supporters is that doing it on a state level will only encourage people to move to the state and potentially not work and drag down the healthcare system. And so, to avoid this, it must be done federally.

You must log in to answer this question.

Not the answer you're looking for? Browse other questions tagged .