Federalism and Responsibility for Health Care
by Douglas MacKay and Marion Danis
Political philosophers often formulate the problem of distributive justice as
the problem of how the government ought to distribute different types of
goods—for example, income or health care—to its citizens. They therefore presuppose
that the government is a unitary agent that governs its citizens directly.
However, although a number of governments are unitary in this way, many are
federations, exhibiting a division of sovereignty between two or more levels of
government having independent grounds of authority. In contrast to unitary
states, therefore, within a federation, two or more levels of government directly
govern their citizens and are directly accountable to them.
Because of the way in which different levels of government in a federation can
separately affect the distribution of goods in society, federations face resource
allocation problems that are far more complex than those of unitary states. In
addition to determining what a just distribution of goods is, federations must also
determine (1) whether distributive justice is a shared responsibility amongst different
levels of government, and, if so, (2) how this shared responsibility should
be allocated between them.