Impact of Power Fragmentation

Even as the framers of the Constitution were enamored of Locke's political philosophy, they and many other early Americans were heavily influenced by French philosopher Baron de Montesquieu's The Spirit of the Laws (1949 [1748]), in which he urged that the powers of governments should be separated in order to thwart the development of tyrannical states. Accordingly, the framers divided the very limited powers of the national government they established into executive, legislative, and judicial branches—each with the power to check the actions of the others. This structure, of course, made it difficult for government to act and thereby interfere with individuals and their property.

The separation of powers exacerbated what was already a characteristic of the American political system, the endemic fragmentation of power in a federal form of government. Not only did the state governments retain most of their power in the federal system but, reflecting the influence of Montesquieu, the powers in each of them were also separated. The fragmentation of governmental power in the United States is astounding: Altogether, there are some 80,000 governments—including counties, municipalities, special district governments, and independent school districts, as well as the state and national governments—and the powers of each of these are usually separated, and even further fragmented. Therefore, generally speaking, government intervention of a sweeping nature is difficult in the American political system. Health policies and other policies tend to be incremental rather than systemic or comprehensive.

One consequence in the health arena, for example, is that various American presidents since the 1920s have failed in their efforts to secure national health insurance, including President Bill Clinton who declared it the prime legislative goal of his first term (1992-1996). One of them may well have succeeded if he had been the head of a disciplined ruling party in a parliamentary system of government, with no separation of powers. Another consequence is that many important health policies are carried out in disparate and uneven fashions throughout the nation because they are primarily the responsibility of state and local governments. These responsibilities include: public health; regulation of hospitals, nursing homes, home health agencies, hospices, and other healthcare provider organizations; licensing of healthcare professionals; and regulation of private health insurance plans. Still another and related consequence is that it is difficult to establish national standards for healthcare.

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