ABSTRACT
Nationally and in the states influential persons in the public and private sectors have exploited the contradiction, transposing conflict about particular policies to debates about democratic theory, constitutional law, and managerial capacity. The politics of health care in the 1990s offer many examples of the effects of the contradiction. Large employers who self-insure for their employees' health services have exploited it in lobbying Congress to continue preempting state laws that would regulate their health plans and require them to participate in paying for care for uninsured persons. The chapter explores the persistence of the contradiction between the increasing competence of state government and ongoing disparagement of it, emphasizing the implications of the contradiction for health policy. The national government asserted greater authority over the states in the 1960s than at any time since the Civil War. Most commentators have exaggerated both the incompetence of the states and the extent of the centralization imposed on them in the twentieth century.
