The level of government responsible for implementing policies affects intent, services provided, and ultimate outcomes. The decision about where to locate such responsibility is the federal design dilemma faced by Congress. Taking a new approach to this delegation and decentralization, The Federal Design Dilemma focuses on individual members of Congress. Not only are these legislators elected by constituents from their states, they also consider the outcomes that will result from state-level versus national executive branch implementation of policies. Here, Pamela J. Clouser McCann documents congressional intergovernmental delegation between 1973 and 2010, and how individual legislators voted on decentralization and centralization choices. Clouser McCann traces the path of the Affordable Care Act from legislative proposals in each chamber to its final enactment, focusing on how legislators wrestled with their own intergovernmental context and the federal design of health insurance reform in the face of political challenges.