From COVID-19 response to the overturning of Roe v. Wade, the results of 50 states having individual approaches to public health, medical outcomes and healthcare access raise troubling questions. A husband-and-wife team of University of Utah professors dig into the ethics of the American healthcare system in States of Health: The Ethics and Consequences of Policy Variation in a Federal System.

Leslie P. Francis is a professor of law and philosophy with a background in bioethics, and John G. Francis is a professor of political science with a focus on European comparative politics, federalism and comparative regulatory policy. The spouses had partnered on three previous books together. When looking for their next project, they decided to examine the consequences of states opting out of Medicaid expansion and what power federalism could have in protecting American citizens’ health. But soon more news events and landmark cases expanded their focus.

The result is States of Health. The book examines the tensions between state and federal powers in a number of areas, including reproductive rights; gender-affirming care; medical marijuana; public health and pandemics; right-to-try laws; patient confidentiality; and care quality and life expectancies.

In this episode of The Modern Law Library, the ABA Journal’s Lee Rawles speaks with the Francises about their collaborative writing process, and what conclusions they have drawn about the benefits of federalism and states’ rights.

The Francises argue that since it is the federal government that determines citizenship and census decisions, state differences go too far when they make “basic decisions about who counts at all, and what it means to count.” They add, “Movement is a critical aspect of who counts: the ability to come and go, or to leave one state more permanently for another.” The Francises argue that freedom of movement for the purpose of medical treatment is crucial for patients, but also point out when states control licensure for medical providers, that too can restrict freedom of movement.

The value of 50 individual laboratories of democracy can be appealing to a scientific mind. But at what point can it be argued in the healthcare space that a federal government needs to step in, if the outcomes in some of those laboratories are decreased lifespans and higher mortality?