Abstract

The apportionment of responsibility for health policy within multi‐level states should be sensitive to a number of conflicting normative pressures, some of which militate for placing decision‐making authority at the higher reaches of policy‐making structures, while others would seem to require placing them lower down this structure. The principle of subsidiarity is a structural principle that addresses in a manner that is neutral with respect to these values a way of addressing the conflicting claims of these values. Standard accounts of federalism fare poorly with respect to the criterion of subsidiarity. While central governments are at first glance better equipped to apply such a principle to the issue of the distribution of authority, there are strong empirical grounds for thinking that centralized governments will non‐neutrally privilege central authorities in applying the principle. Federal structures that admit of overlapping jurisdictions, and that therefore require that deliberation among federal parties occur as a condition of the problem of the distribution of powers over health care being solved, are most amenable to solving problems of distribution of authority.