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American Federalism in Practice

The Formulation and Implementation of Contemporary Health Policy

Michael Doonan

Publication Year: 2013

American Federalism in Practice is an original and important contribution to our understanding of contemporary health policy. It also illustrates how contentious public policy is debated, formulated, and implemented in today's overheated political environment.

Health care reform is perhaps the most divisive public policy issue facing the United States today. Michael Doonan provides a unique perspective on health policy in explaining how intergovernmental relations shape public policy. He tracks federal-state relations through the creation, formulation, and implementation of three of the most important health policy initiatives since the Great Society: the State Children's Health Insurance Program (CHIP) and the Health Insurance Portability and Accountability Act (HIPAA), both passed by the U.S. Congress, and the Massachusetts health care reform program as it was developed and implemented under federal government waiver authority. He applies lessons learned from these cases to implementation of the Affordable Care Act.

"Health policymaking is entangled in a complex web of shared, overlapping, and/or competing power relationships among different levels of government," the author notes. Understanding federal-state interactions, the ways in which they vary, and the reasons for such variation is essential to grasping the ultimate impact of federalism on programs and policy. Doonan reveals how federalism can shift as the sausage of public policy is made while providing a new framework for comprehending one of the most polarizing debates of our time.

Published by: Brookings Institution Press

Front Cover

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pp. 1-3

Title Page

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p. 4-4

Copyright Information

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p. 5-5

Table of Contents

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pp. v-vi

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pp. vii-viii

This book is the result of more than a decade of exploration of intergovernmental relations and U.S. health care reform at the national and state levels. It has been influenced by my work in Congress, for federal government agencies, and with the states as well as by my academic work at the Heller School for Social Policy and Management at Brandeis University, ...

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1. Federalism Creates Health Policy

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pp. 1-15

Friends in my small town know that I have been involved in national health care reform efforts as well as those in our home state of Massachusetts. When conversation at the local pub turns to health care, they’ll ask me questions. Because I’m a political scientist, not a medical doctor, I don’t get pelted with questions everywhere I go, ...

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2. CHIP: Federalism in Congress

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pp. 16-29

The State Children’s Health Insurance Program of 1997 (CHIP) was enacted during an especially turbulent time in American politics. The Clinton health care plan had failed, and conservative members of Congress were emboldened to make some big moves. ...

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3. CHIP: Federalism and Rulemaking

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pp. 30-42

Laws passed by Congress do not emerge as finished products. Before they can be fully implemented, they have to go through the underappreciated but crucially important process of administrative rulemaking. This phase defines how a law will work in the real world, thereby creating policy. ...

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4. CHIP: Federalism and Implementation

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pp. 43-56

Implementation is where the rubber hits the road, where abstract policies and rules have real impacts on people, where intergovernmental relations are solidified in practice. As a process, implementation turns out to be every bit as political as rulemaking. ...

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5. HIPPA: Federalism in Congress

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pp. 57-70

When I tell my graduate students, “Today we will be talking about something truly fascinating [dramatic pause]: health insurance regulation,” the line never fails to elicit groans. The truth is that health insurance can be intriguing—except for the parts that are bone dry. ...

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6. HIPAA: Federalism and Rulemaking

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pp. 71-83

The rulemaking process that turned HIPAA legislation into policy should serve as a cautionary tale for national reform through the Patient Protection and Affordable Care Act. The HIPAA rule used the threat of a federal takeover of a state regulatory function to enforce the insurance portability provisions. ...

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7. HIPAA: Federalism and Implementation

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pp. 84-98

As HIPAA became the law of the land, the federal government continued to defer to the states in important ways. Because of passive federal oversight, states took control of the scope and shape of insurance reforms, particularly in the individual market. ...

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8. Massachusetts Leads the Way

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pp. 99-114

Today, the suggestion that a Republican administration had anything to do with Massachusetts health care reform would be more shocking to folks on the right than the left. After President Obama used Massachusetts as a model for national reform, Republican and Tea Party activists started to take a much dimmer view of the scene in Massachusetts. ...

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9. Federalism and the Affordable Care Act

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pp. 115-130

Beginning with President Franklin D. Roosevelt’s New Deal in the 1930s, Americans began to look to the federal government to remedy some of the country’s most pressing social, economic, and environmental ills. The Social Security Act of 1935 created federal pensions, unemployment insurance, and welfare assistance programs. ...


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pp. 131-152


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pp. 153-159

Back Cover

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p. 169-169

E-ISBN-13: 9780815724841
E-ISBN-10: 0815724845
Print-ISBN-13: 9780815724834

Page Count: 159
Publication Year: 2013