Health and Care: who decides

Health and care decisions in the United States are divided among Congress and federal agencies, fifty state governments, thousands of local bodies, the courts and sometimes voters themselves. The federal government runs Medicare and finances most of Medicaid, but states decide much of who Medicaid covers, regulate most private insurance, and hold the police power on which public health rests. Knowing which body controls which lever is the first step in turning a health priority into a request someone can act on.

In plain words

If you are worried about health care, the right person to talk to depends on what worries you.

Medicare, the program for most people 65 and older, is run by the federal government. Medicaid, for many people with low incomes, is shared: Washington pays most of the bill, but your state decides much of who qualifies. Private insurance sold in your state is mostly regulated by your state. Restaurant inspections, disease tracking and vaccination clinics are usually run by a state or local health department.

This page maps those powers. It explains the main federal laws, what states control, what local bodies do, and what courts have said about the limits.

Defined terms

Medicare. The federal health insurance program for most people 65 and older and some younger people with disabilities, administered by CMS.

Medicaid. A health coverage program for eligible people with low incomes, jointly financed by the federal government and the states and administered by states within federal rules.

FMAP (Federal Medical Assistance Percentage). The share of a state’s Medicaid costs paid by the federal government.

Medicaid expansion. The option, created by the Affordable Care Act (ACA), for states to extend Medicaid to most low-income adults, with an enhanced federal match for that group.⁠⁴

Marketplace (exchange). The ACA system through which individuals buy subsidized private insurance, run either by a state or by the federal government.

Police power. The general authority of states to regulate for health, safety and welfare, which the Constitution does not grant to the federal government in the same general form.

Certificate of need (CON). A state requirement that certain health facilities obtain approval before opening or expanding.

Evidence: the federal role in health and care

The federal government decides health and care policy through Congress, which writes the law and appropriates money, and through agencies of the Department of Health and Human Services, including CMS (Medicare, Medicaid, the ACA marketplaces), the Food and Drug Administration (drug and device approval) and the Centers for Disease Control and Prevention (surveillance and guidance).

The federal government’s largest direct health commitment is Medicare. CMS reports that Medicare spending was $1,118.0 billion in 2024, about 21% of national health spending.⁠¹ Medicare’s hospital benefit is financed through a trust fund that its trustees project will be depleted in 2033,⁠² so the decisions that matter most for Medicare’s future (taxes, provider payments, benefit design) belong to Congress.

Federal law also sets national floors that apply regardless of state policy. The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires Medicare-participating hospitals that offer emergency services to provide a medical screening examination when someone requests care for a possible emergency, to stabilize emergency conditions, and to arrange an appropriate transfer when they cannot.⁠³

The state role in health and care

States make many of the decisions that most directly shape coverage and access.

Medicaid choices. States administer Medicaid within federal rules and share its cost. KFF reports that in federal fiscal year 2024, Medicaid spending totaled $919 billion, of which the federal government paid 65% and states 35%.⁠⁴ The federal match varies with state per capita income: the floor is 50%, which applies to ten states in federal fiscal year 2027, while Mississippi has the highest regular rate at 77%.⁠⁴ States that adopted the ACA expansion receive a 90% federal match for adults covered under it.⁠⁴

Whether to expand Medicaid became a state choice through the courts. In National Federation of Independent Business v. Sebelius, decided June 28, 2012, the Supreme Court remedied a constitutional violation by “precluding the Secretary from applying §1396c to withdraw existing Medicaid funds” from states that declined the expansion.⁠⁵ In practice, this made the expansion optional. As of KFF’s October 2026 tracker, 41 states including the District of Columbia had adopted the expansion and 10 had not.⁠⁶

Insurance regulation. Federal law leaves most regulation of insurance to the states. Under the McCarran-Ferguson Act, “the business of insurance, and every person engaged therein, shall be subject to the laws of the several States” that regulate or tax that business.⁠⁷ State insurance departments license insurers, review many policy forms and handle consumer complaints.

Marketplaces. States choose whether to run their own ACA marketplace. For plan year 2026, KFF counts 21 state-based marketplaces, 2 state-based marketplaces using the federal platform (Arkansas and Oregon), and 28 federally facilitated marketplaces.⁠⁸

Facility supply. Many states control the building of health facilities. NCSL reports that as of January 2025, 35 states and Washington, D.C., operate certificate-of-need programs, while 12 states had fully repealed or let their programs expire as of January 1, 2024.⁠⁹ NCSL summarizes the case for CON as controlling costs by preventing excess capacity and protecting access in underserved areas, and the case against as protecting incumbent providers and lacking evidence of cost control.⁠⁹

Public health powers and licensing. States hold the police power that underlies vaccination requirements, quarantine and many health regulations. In Jacobson v. Massachusetts (1905), the Supreme Court upheld a state compulsory vaccination law, while noting that courts could intervene if a regulation were applied in an arbitrary or oppressive way.⁠¹⁰ States also license physicians, nurses and other professionals, and set their scope of practice.

The local role in health and care

Local governments carry out much of public health and some direct care. County and city health departments typically run disease investigation, restaurant inspection, immunization clinics and environmental health programs, though the division of duties between state and local agencies differs from state to state. Some places run public hospitals through a local government body: in Texas, Harris Health describes itself as “the public healthcare safety-net provider serving the residents of Harris County,” and its legal name, Harris County Hospital District, is a governmental entity.⁠¹² The Census Bureau counted 90,837 local governments in 2022, with growth since then concentrated in special districts.⁠¹¹ Which of those districts deal with health, and how, depends on each state’s law.

Local bodies usually cannot change Medicaid eligibility, insurance rules or Medicare. Their levers are local taxes and levies (where state law allows), local health orders within state law, zoning for health facilities, and how they run their own programs.

A map of health and care authority

The role of courts and voters in health and care

Courts and voters also decide health questions. Federal courts decide whether federal health laws exceed Congress’s powers, as in the 2012 Medicaid decision⁠⁵ and whether state public health rules violate individual rights, as Jacobson framed the question in 1905.⁠¹⁰ State courts interpret state constitutions, which in some states contain provisions on public health or welfare.

In states that allow citizen initiatives, voters can also place health questions on the ballot directly. Ballot measures can therefore move a decision from the legislature to the electorate, but only in states whose constitutions provide that process. See Jurisdictions.

Competing interpretations of health and care authority

People disagree sharply about where health authority should sit, and each position has a principled case.

National uniformity. One view holds that health coverage should not depend on a person’s state. Supporters point to the split in Medicaid expansion.⁠⁶ as evidence that state control produces unequal protection for similar people.

State and local experimentation. Another view, rooted in federalism, holds that states should design programs suited to their populations and budgets, and that differences between states produce evidence about what works. Supporters see the Medicaid expansion decision as a defense of state choice against federal pressure.

Market and professional self-regulation. A third view holds that many government controls, such as certificate-of-need rules and narrow scope-of-practice laws, protect incumbents more than patients, and that authority should shift toward patients and competition. NCSL’s summary of the CON debate reflects this disagreement⁠⁹

Public health authority versus personal autonomy. Disputes over vaccination and emergency orders during the COVID-19 pandemic revived the question Jacobson addressed: how far state police power extends over individual choices. Some argue for strong public health powers in emergencies; others argue for tighter legislative and judicial checks on executive health orders.

Application to this framework

• My Vote Forward treats “who decides” as part of understanding a subject. A priority for health and care is shown with a map of the authorities that hold each lever.
• When a specific proposal is discussed, the framework asks which body has legal authority to adopt it, who pays, and what depends on it. See Proposals.
• Hypothetical example: participants in a county rank Health and Care first and many mention nursing home staffing. The relevant authorities include the state Medicaid agency (which pays for much long-term care), the state licensing agency, and federal CMS rules for nursing homes, not the county council alone. The framework’s job is to make that visible.
• Because layered authority varies by state, examples are labeled with their state and date. See Jurisdictions.

Unresolved questions

• How should a framework present authority over a concern that is split three ways, such as long-term care, without making participation feel futile?
• Should priorities be collected separately for each level of government, since a city cannot change Medicare?
• How often should the authority map be updated, given that state laws on Medicaid, CON and public health powers change frequently?
• How should results be reported when the body that decides (for example, a state legislature) covers many communities that rank priorities differently?