Ezra Klein dismisses the federalist approach:

The thing that costs money in public health-care programs is subsidies for people who can't afford care on their own. That group gets larger during recessions. But at the same time, state tax revenues drop during recessions. So at the very moment when the programs are most needed and most expensive, the states -- which by and large cannot deficit spend -- have the least money to keep them running. The results have always been cuts.