gins Camille Ascuaga's account (Chapter Eight) of Massachusetts' much publicized experiment in guaranteeing universal access to health care. The Massachusetts law received national attention during the 1988 presidential campaign when the Democratic candidate, Massachusetts Governor Michael Dukakis, hailed it as a model for a nationwide effort at guaranteeing universal access. However, much like that state's "economic miracle," this Dukakis legacy has also fallen on hard times. Ascuaga's account is a sobering reminder of how quickly political and economic events can derail state policy reform. The Massachusetts experiment, whatever its fate--and it is still uncertain--provides important lessons for those interested in health care policy. Of particular significance was the effort to enlist the support of the small- business community in the policymaking and implementing process. Since small-business people are, for economic reasons, often opponents of expanding health care access to the working poor, the Massachusetts experiment remains important to students of health policy.
In the final chapter of the book, Bruce Jennings shifts the focus of the discussion from the substance of health policy innovation and reform to the moral and ethical nature of the process by which policy change takes place. In particular, he is concerned about the role of democratic values in helping reform the health policymaking process. He suggests that the innovative content of recent reform efforts has raised new ethical issues and generated innovative forms of policy discourse. Jennings argues that citizen involvement in health policy formation, illustrated most dramatically by the grass roots organization, Oregon Health Decisions, will be increasingly used to legitimize the allocation, prioritization, and, perhaps, rationing of health care resources in the future. In this sense, according to Jennings, democratic values will have an increasingly important role to play in the policymaking process. And, most importantly from the perspective of this book, this is most likely to occur at the subnational level.