The Patient Protection and Affordable Care Act (ACA) substantially alters the respective roles of the federal and state governments in health care policy. Beyond the individual mandate, the ACA presents many questions of federalism, both constitutional and policy-related. This paper, prepared for a symposium sponsored by the Kansas Journal of Law & Public Policy, addresses some of these federalism issues. After outlining some of the policy considerations for determining the proper federal and state balance in health care policy, it identifies constitutional limitations on the federal government’s ability to direct or even influence state policy choices, before discussing how federal policy decisions can influence state policy choices and potentially retard positive reform efforts at the state level.


health care, federalism, affordable care act, health care reform, cooperative federalism, conditional spending

Publication Date


Document Type


Place of Original Publication

Kansas Journal of Law & Public Policy

Publication Information

Cooperation, Commandeering, or Crowding Out?


20 Kansas Journal of Law & Public Policy 199 (2011)


COinS Jonathan H. Adler Faculty Bio