ARTHUR L. LEVIN
Sandwiched between the federal and local governments, many of which had strong departments of health as far back as the early 1800s, the state governments have played a significant, though often ambiguous, role in national health affairs. They have frequently found themselves in the unenviable position of having health policy making preempted by Washington, while being criticized by local governments laboring under the day to day management of their health problems.
Nevertheless, the states have remained an essential part of the tripartite governmental health structure. Indeed, they are more important now than ever before. Federal health spending increased some 170 percent in the 1960s, and in 1974 federal outlays for health will total more than $23 billion, over $5 billion more than two years ago. Most of these increases have been to plan, finance, or otherwise support the delivery of health services. And of these moneys, with the important exception of the Medicare program, most are funneled through the states.
With the passage of the Medicare and Medicaid acts in 1965, federal spending to finance health services took a quantum leap. The increment of several billion additional dollars for health placed a serious strain on intergovernmental relations. The federal government looked to the states to control health prices while localities, hard-pressed for funds, resented state efforts to police their operation of health programs or to limit their use of federal-state money.
Medicaid was the most significant source of intergovernmental conflict. This law, enacted in July 1965, required that as a condition for