In this paper, we aim to discuss the implications and lessons that can be learnt from the ongoing process of federalism affecting the Italian National Health System (INHS). Many countries are currently taking decisions concerning the decentralization or re-centralization of their health-care systems, with several key issues that are illustrated in the recent history of the INHS. The decentralization process of INHS has produced mixed results, as some regions took advantage of it to strengthen their systems, whereas others were not capable of developing an effective steering role. We argue that the mutual reinforcement of the decentralization and recentralization processes is not paradoxical, but is actually an effective way for the State to maintain control over the equity and efficiency of its health-care system while decentralizing at a regional level. In this perspective, we provide evidence backing up some of the assumptions made in previous works as well as new food-for thought - specifically on how governmentality and federalism should meet - to reshape the debate on decentralization in health care.