Date of Award


Document Type

Campus Access Dissertation

Degree Name

Doctor of Philosophy (PhD)


Public Policy

First Advisor

Mark Warren

Second Advisor

Jerry Cromwell

Third Advisor

Edward Alan Miller


In 2012, the Massachusetts Legislature passed Chapter 224, crafted in reaction to high and rising healthcare costs that threatened access to healthcare and the state’s fiscal stability. This case study examines how legislators defined this problem and how they used that definition in creating Chapter 224. This dissertation is a qualitative study involving semi-structured, in-depth interviews of legislators, key staff and representatives of outside stakeholders as well as secondary data sources.

This study found that as legislators were pragmatists, operating with limited time, technical information and resources, they relied on politically feasible policy solutions to understand the root causes of an issue. These politically feasible solutions were determined via a stakeholder consensus process mediated by committee chairmen. Policy solutions were determined politically feasible if the solutions did not threaten consensus, as this consensus was necessary to advance healthcare reform, and to access technical information otherwise unavailable to legislators. Based on the importance of the stakeholder consensus, Partners Healthcare, the largest healthcare provider in the state, and other providers were able to limit the scope of the bill by implying that certain solutions were not politically feasible, for example price regulation.

Ultimately, the key architects of the bill came to understand the healthcare cost problem as one created by overutilization of healthcare services. Legislators crafted a law that incorporated many different remedies to overutilization such as requiring the implementation of alternative payment methodologies. The legislators did not understand or address one of the major causes of high costs, price variation, because there were limited politically viable solutions in 2012.

Scholars have for the most part understood problem definition as preceding and shaping policy solutions with stakeholders driving that process. In this study, the reverse is the case; legislators drove the legislative agenda and used solutions to understand the issue. Future research will have to test the generalizability or transferability of these findings to other states or policy arenas. Nevertheless, the findings in this case are important because they suggest that the relationship between legislator’s problem definition and solution selections is more nuanced and interrelated than previously understood.


Free and open access to this Campus Access Dissertation is made available to the UMass Boston community by ScholarWorks at UMass Boston. Those not on campus and those without a UMass Boston campus username and password may gain access to this dissertation through resources like Proquest Dissertations & Theses Global or through Interlibrary Loan. If you have a UMass Boston campus username and password and would like to download this work from off-campus, click on the "Off-Campus UMass Boston Users" link above.