Capital Commentary is the weekly current-affairs publication of CPJ, written to encourage the pursuit of public justice.

Health Care for a Healthy Polity

Tim Sherratt


June 12, 2006

By July 2007, universal health-care coverage will be implemented in Massachusetts. This accomplishment is instructive for both the health of the political order and the physical health of its citizens.

Ever since a failed federal attempt at macro-reform in 1993, both Democrats and Republicans have shied away from comprehensive initiatives. Many would agree with Robert Frank of the Johnson School of Management at Cornell University that the federal government has "dropped the ball" on health care. But some nineteen states have recently decided to go where the federal government has feared to tread.

Massachusetts seems to have achieved the most impressive result to date because the state government pits a Republican governor against a Democratic legislature. Paradoxically, divided government in the Bay State seems to have played an important role in ensuring that comprehensive health-care legislation will be implemented in 2007.

The Massachusetts law offers nearly universal coverage, requires both individuals and employers to participate, and pays in full the premiums of those below the federal poverty level. Other low-income residents will pay monthly premiums varying from $30 to $140 (AP, 6/4/06).

The law's most creative feature is the Commonwealth Health Insurance Connector, a cafeteria-type plan that allows employees to buy coverage with pre-tax dollars. This has been likened to "one-stop shopping" by supporters of the plan, as opposed to the "one-size-fits-all" moniker typically saddled on government-run health-care programs. The Connector combines government's capacity to create a large enough pool of participants with individual choice among plans.

Massachusetts has an advantage in that its half-million or so uninsured represent a number well below the national average. When the plan is implemented, this will shrink to around 35,000.

How did Massachusetts' legislation succeed politically? First, there were policy incentives to set aside both Democratic fears of deregulation and Republican fears of intrusive government. For the Democratic legislature the strongest incentive was elimination of an uninsured underclass that relied on emergency or substandard care. For Republican Governor Mitt Romney there was the prospect of a major policy victory as he positions himself for a presidential run. Widespread press treatment of the law as a model for other states has followed its passage.

The balance of power helped too. The Massachusetts governor has a line-item veto. The Massachusetts legislature has enough votes to override it. So when the governor vetoed several provisions of the new law to respond to concerns expressed by the business community, the House and Senate promptly overrode the veto. But rather than frustrating efforts at reaching compromise, these procedures appear to have oiled the political machinery to help pass the legislation.

American federalism has a checkered history. It has preserved local prejudice to the detriment of citizens who could get redress from neither Congress nor the Supreme Court. Slavery and Jim Crow tell this side of the story. On the other hand, American federalism has sometimes preserved a kind of subsidiarity in which decisions are made at the lowest level of social authority so as to remain responsive to those affected by them. The recent Massachusetts health-care law represents this face of federalism. The law possesses the added virtue of government acting in solidarity with its weakest residents. If Massachusetts can succeed with this new health-care policy, then it might prove to be a model for other states, making comprehensive federal legislation unnecessary.

—Timothy Sherratt, Political Studies
    Gordon College


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