There are a couple things that others haven't pointed out. First, Erdoğan has more power in turkiye than the president has in America (for now).
Second, individual states are not subordinate to the federal government; they have their own powers. Anything not specifically granted to the federal government is controlled at the state level. Healthcare is one of those things. There are some hooks the federal government can use to control parts of healthcare, but not the whole system.
There are some states with much better healthcare systems than others (like Massachusetts). Massachusetts is a fun example because their health care system was established by a Republican governor, and then a watered down version was implemented at the federal level as Obamacare, to the ire of the Republicans.
I think it's relatively new. It might also be seasonal. Last time I was there, they let you hike all the way up to the scout lookout before you need the permit. Basically as soon as you get to the bottleneck of the chain section.