Joined by a panel of experts on health care policy, two University of Utah professors discussed their new book, “States of Health: The Ethics and Consequences of Policy Variation in a Federal System.” The book is authored by Leslie Francis, professor of law and philosophy, and John Francis, professor of political science. It explores the morality of states having vastly different policies on healthcare, which impacts the quality of American citizens’ lives between state lines. The event took place at the S.J. Quinney College of Law on Sept. 27.
“We want to argue and explore both the strengths and the weaknesses of federalism and to think about whether we put certain kinds of decisions in … the right places,” Leslie Francis said.
Policies Across States
The book explores various policy decisions, from the federal government’s and states’ roles in funding healthcare to differences in licensing requirements.
“There are huge [licensing] differences among the states that you wouldn’t think,” Leslie Francis said. “A nurse practitioner can practice independently in Illinois, [but] if they move across the river to Missouri, they can’t.”
Phillip McMinn Singer, associate professor in the Department of Political Science at the U, said the “States of Health” brings ethics into the forefront of healthcare policy.
“What I loved the most about this [book] was the overlaying … ethics of it and thinking about … what the price of federalism is, not in dollars and cents, but in the lives [and] the well-being of the citizenry,” Singer said.
Leslie Francis said one key theme of their book are that healthcare policies between state governments can diverge so dramatically that they become intolerable. The second key theme is that the interconnectedness of every state makes us all concerned with each community’s well-being.
She pointed to Mississippi to illustrate this. Mississippi’s average lifespan is nine years lower than Hawaii’s average life expectancy.
“And Mississippi is the largest net taker in federal funds … so we all have an interest in what’s going on in Mississippi,” Leslie Francis said.
Freedom of Movement
Despite the country’s stark health disparities, the authors do believe federalism has advantages. They argue that it allows for policy experimentation and allows citizens to move freely to states whose policies align with their worldviews.
In an op-ed published in Newsweek, Leslie Francis and John Francis wrote that the Supreme Court’s decision in Dobbs v. Jackson, which granted states the ability to ban abortions, showed federalism’s benefits but also its drawbacks. They raised concerns about recent threats to restrict citizens’ freedom of movement, notably with the enactment of “abortion trafficking” laws.
“Federalism has the advantage that states may agree to disagree, but this advantage will be lost if states can impose their will on what their residents do elsewhere,” they wrote.
Abortion and the freedom of movement in a federal system were significant topics of discussion for the panel.
On Sept. 4, Texas sued the federal government in an attempt to obtain the medical records of women who receive abortions out-of-state. Leslie Francis described this as a “very frightening” challenge to a state’s ability to protect medical privacy.
Kif Augustine-Adams, Ivan Meitus Chair and law professor at Brigham Young University said challenges to the right to travel would be a “core issue as we move forward in time.” She noted that 171,000 women went out of state for an abortion in 2023. 14,000 of those were from Texas alone.
Singer said the women going out of state for an abortion are “not randomly assigned.” They have the means to take time off work and travel for the procedure.
“One of the strong points in the book is the kind of inequities and disparities federalism magnifies,” he said. “And I think a post-Dobbs world really magnifies this.”
