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This paper explores the impact of the federal structure of American government on health policy through the examination of three case studies of unsatisfactory policy: Medicaid cutbacks; provider licensure; and health planning under P.L. 93-641. Problems arise in all three areas because of a disjunction between administrative or regulatory responsibilities and financial accountability. How the division of responsibilities among different levels of government might be managed better is examined briefly, in the context of possible state roles under a system of national health insurance.