Editor's Note: Health Politics and Policy in a Federal System

For reasons that elude me, over the years, federalism, one of the stodgiest subfields in the social sciences, seems to have sparked an unusual level of creativity in visual imagery. Perhaps revealing a certain hunger for conceptualization, at one time the prevailing metaphor of American federalism was the triple "layer cake." In this motif, the national, state, and local governments (the individual, autonomous layers) were joined, to be sure, one atop the other to form a whole (the cake), but each had its independent flavors: roles to play, responsibilities to perform, and separate categories of policy to dominate. More formally, this arrangement was known as "dual federalism," with the national government and the states (from which local governments derive their formal authority) functioning in more or less separate spheres predicated on separate and distinct constitutional ties to the people (Peterson 1995: 55). Anyone who has watched children collectively devour cake at a birthday party knows that the imagery of the layer cake is too simplistic--before long the purity of the strata is violated by all kinds of blending. Almost from the beginning of the republic, federalism in the United States has involved complex interactions and interrelationships across the levels of government (Elazar 1962).

Recognizing the links that develop among public officials from multiple governments who operate in the same policy domain, especially the members of the administrative branch of national, state, and local agencies, Deil Wright (1978) suggested instead the metaphor of the "picket fence." Federalism is not layers in isolation but rather layers joined sturdily together by vertical posts (the cross-level interactions among officials). Who can begrudge the imagery of the picket fence, so evocative of the security provided by the bounded grassy lawns and backyards along the avenues of America's allegorical small town? Just as "good fences make good neighbors," so too this depiction of the country's approach to national, state, and local governance lent an air of rationality and confidence to the organization of a geographically expansive and demographically textured society. One might say that the "white" picket fence, however, did not offer sufficient protection against the exploitation of the states' rights rubric by white elites who denied constitutional rights, political justice, and economic opportunity to people of color.

In part because of the darker implications of federalism, the power and domestic policy reach of the national government grew substantially in the postwar period on the foundations of previous intergovernmental engagements and the unusually sweeping involvement in the economic and social life of the nation launched by the New Deal. The 1960s, with John F. Kennedy's New Frontier and Lyndon B. Johnson's Great Society --together a compendium of social policy and civil rights initiatives that brought resources, rules, and enforcement from the nation's capital to the nation's communities and states--undermined the visual veracity of the picket fence. So, too, did the national highway construction of the Eisenhower years and the flourishing of environmental programs in the 1970s.

As the layer cake hit the blender and the picket fence lost its rigidity, another metaphor took their place: "the marble cake." No longer are there distinct zones of autonomous flavors, but rather a far more thorough intermeshing of ingredients: revenue sources and streams, grants, incentives, origins of initiatives, administrative and enforcement responsibilities, and the like. For those less enamored with culinary visions, Morton Grodzins (1966) described this form of intergovernmental engagement as "cooperative federalism," with the federal government frequently taking the lead on a number of issues, but the states still potential venues of policy innovation (Sparer and Brown 1996).

In many respects the story of health care politics and policy making in the United States is inseparable from issues of federalism, all the more so as both the image and reality of the marble cake have taken hold. The Journal of Health Politics, Policy and Law has often in...