The Massachusetts universal health insurance law: A case study of making health care policy

This is a case study of the process in Massachusetts that led to An Act to Make Health Security Available to All Citizens of the Commonwealth and to Improve Hospital Financing in 1988. It is set within the historical framework of the political economy of health care in the United States. The health care product emerged in the commodity form, the health care sector grew to be one of the most highly profitable sectors of the economy. The financing system became enmeshed in capital-labor relations through the development of employment-based health insurance.^ The process in Massachusetts is analyzed through the role of capital, the working class and the State. The structurally powerful players include medical capital (hospitals, physicians, insurers, biomedical technology firms); nonmedical capital (traditional industries, manufacturing, large employers); competitive capital (small business); the working class (organized labor, low wage, disenfranchised); the State.^ In the 1980\u27s, hospital rates in Massachusetts far exceeded the nation. As a result of shifts in the structure of the economy, an increase in the number of uninsured workers, accelerated a cost-shift for hospital care to employers who provided employee health insurance. Fifteen months of political negotiating ensued, primarily between the hospitals and big business over the issue of uncompensated care, with the State attempting to achieve a settlement.^ On the surface the debate centered on ensuring universal access to health care. In reality, it was a battle between two factions of capital over who would pay the health care bill. In the end the hospitals got massive revenue increases and big capital had its cost liability capped. The State took over hundreds of millions of dollars in health care costs to glue the deal together.^ This study highlights the structural basis of power in capitalist society. The most powerful players, the hospitals, controlled the definition of the problem, and dictated the solutions. The State was forced to align itself with big capital in order to assert itself into the negotiations. The question of access to health care was irrelevant to the process and the outcome.