April 17, 2026
Dear Interested Readers,
A Celebration of a Past Victory In a Time of Great Concern
There was an unusual gathering this past Monday at historic Faneuil Hall on Boston’s waterfront. The current governor of Massachusetts, Maura Healey, welcomed past governors Michael Dukakis, William Weld, Deval Patrick, and Mitt Romney to a celebration of the twentieth anniversary of a groundbreaking piece of bipartisan legislation, Chapter 58 of the Acts of 2006 of the Massachusetts General Court, An Act Providing Access to Affordable, Quality, Accountable Health Care. That piece of genius was better known as “Romneycare,” and I like to think of it as the parent of “Obamacare.” The full name of the bill that President Obama signed on March 23, 2010, is the Patient Protection and Affordable Care Act, or if you prefer, the Affordable Care Act or ACA.
There was an article in the Boston Globe this week about the twenty-year run-up to the enactment of Romneycare that reminded me of the days, now long gone, when our political divide was not so broad and deep that it prevented individuals from both sides joining in the middle to negotiate something that was a step forward for everyone. WBUR, one of the NPR-affiliated radio stations in Boston, produced a nine-minute segment on April 10, which was a conversation about life before and after Romneycare, with the current Secretary of Health and Human Services for Massachusetts, Dr. Kiame Mahaniah, and John McDounough, an attorney, former state legislator, and healthcare advocate who is currently a professor of healthcare policy at Harvard’s T.H. Chan School of Public Health. When “Romneycare” was signed in 2006, Professor McDonough was very active as the leader of a group advocating for universal coverage, and Dr. Mahaniah was a PCP at The Lynn Health Center, a Federally Qualified Health Center on the North Shore of Massachusetts. I enjoyed their brief conversation, which described some of the long process and negotiations, what was accomplished, and a bit about how things have changed recently. To hear their discussion, click here. I can attest from personal experience that what you hear of their shared memory of the way things were before “Romneycare” is accurate. Reading the articles published by the Globe and WBUR in honor of the anniversary has given me an update on the jeopardy those past accomplishments now face.
The Globe account of the Fanuel Hall celebration was written by Marin Wolf. It was entitled, “A day of commemoration — and concern: State leaders, past and present, mark advent of health care law amid warnings.” Ms. Wolf begins her piece with a word of caution and a call for action at home from Governor Healey:
On the 20th anniversary of the law that revolutionized health insurance in Massachusetts, political leaders and health officials sounded the alarm that affordable and accessible coverage is in peril.
“We face a cost crisis,’’ Governor Maura Healey said at a Faneuil Hall ceremony on Monday marking Romneycare’s anniversary. “Our nation’s health care system is broken, and Washington’s not going to fix it, certainly not anytime soon. And that’s a revolution I think we need to lead again, right here from Massachusetts.’’
I think that she is right when she says that Washington is not about to fix healthcare. Any improvement and innovation in healthcare policy will probably occur first in “blue states” like Massachusetts, or perhaps in small states like Alaska, Maine, or Vermont that have unique access problems affecting significant numbers of people, but it is universally true that the major problem retarding improvement facing the nation and all states is cost. In second place, behind cost are workforce problems. Cost and workforce issues plague even states like Massachusetts, New York, and California, where there is political willingness to innovate in the spirit of the Triple Aim.
When I was a practitioner and healthcare administrator, and until I retired, my primary objective, after endeavoring to improve the patient-centered delivery of care and the quality of our practice, was for our group to be a leader in reducing the cost of the care we provided. I also knew that we had to improve the work experience of all of our employees, not just our physicians, if we were going to adequately provide the care our patients needed. Finance was and is the nut to crack if care delivery is to be improved. We were engaged with other like-minded groups that shared our concern about how cost concerns were impairing the future of practice. I think there was a subconscious, if not explicitly stated, awareness that the gains we had made in the state and nation toward universal access, with the passage first of Romneycare and then the ACA, would be eroded by annual increases in the cost of care that exceeded GDP growth. For many reasons, with the cost of care being the most significant factor, what we feared even as we celebrated expansions in access is happening now. What I never imagined before President Trump’s second term was the attack he would foster on healthcare access, education, and research. Ms. Wolf continues by describing what we all painfully know as we shake our heads in dismay over the cruelty and lack of judgment of this administration. Ms. Wolf focuses on the jeopardy posed by attacks on access to care, which Romneycare improved twenty years ago, and makes her point with just a few words.
The Trump administration is instituting limits on federal health insurance subsidies and on who qualifies for financial aid. Additionally, rising costs for insurance users and the employers who help pay for their policies are making health care harder to access.
The result, health care officials said in interviews, is Massachusetts’ near-universal health insurance coverage is at stake.
Like the ACA in its original form, Romneycare contained a mandate, a Medicaid extension, and a marketplace which was and is still called the “Health Connector.” The connector serves both individuals and small employers. Later in her piece, Wolf notes that at the time Romneycare was passed, there were 400,000 people in Massachusetts without access to care. That was about 6.4%, meaning the gap to close to reach universal coverage was much smaller in Massachusetts than in many states. With the passage of the law, over 98% of the state’s people had a ticket to ride. It seemed to me then that if you weren’t covered, you must have been “off the grid,” or had some difficult-to-understand objection to progress and personal safety, because healthcare coverage was almost impossible to avoid.
I can report from personal experience that knowing that everyone who comes to see you is covered for the care they deserve shifts your concern from “Can we?” to “We can!” I realized in 2006 and later, with the passage of the ACA, that what we were enjoying was terrific, but vulnerable, if costs could not be controlled. I frequently warned anyone who would listen, or read my Friday letter, that since Massachusetts had the highest cost of care in the country, and since the United States had the highest cost of care in the world, and Earth was the only place in the universe that we knew had healthcare, that Massachusetts must have the most expensive care, at least in our galaxy, if not in the universe. There is a somewhat facetious economic principle that I have referenced before called Stein’s Law, which roughly says that if something can’t go on forever, it won’t. Please note that Stein’s law doesn’t predict an eventual resolution of our healthcare cost problem. What I contend is that it predicts a further collapse of our delivery of healthcare, which can’t be sustained in even its dysfunctional state. It predicts that fewer and fewer people will have access to care as costs continue to deprive those without the ability to pay of the care they need. As the report on Monday’s celebration continued, I could see evidence of Stein’s Law in action, as Ms. Wolf reported:
About 22,000 people terminated their coverage through the Health Connector this year after certain tax credit enhancements expired, causing premiums to skyrocket for some low and middle-income families who purchased their own insurance through the exchange, said Health Connector executive director Audrey Morse Gasteier in an interview. That’s double the number who canceled their plans in previous years,
Additionally, President Trump’s One Big Beautiful Bill Act that passed in July took away insurance subsidies for lawfully present immigrants. About 30,000 people in Massachusetts lost coverage because of the policy, Gasteier said.
“Being reminded that Massachusetts can do hard things and that people can do hard things is really needed,’’ Gasteier said. “The challenges we face are actually even greater than those we faced in 2006. It’s a steep hill ahead.’’
Another thing that I would frequently say as I tried to convince my colleagues that it was in our best interest to maximize our efforts to at least stabilize the cost of care was that the voters of Massachusetts were speaking to us using the “megaphone” of the legislature to get our attention about our expensive and often wasteful processes and practices. Romneycare was neither the first nor the last attempt by the General Court of Massachusetts (the state legislature) to improve access to healthcare and reduce costs. Those efforts began in the 1980s when Michael Dukakis was governor. Romneycare was also not the Massachusetts legislature’s last attempt to improve care. There was a series of laws passed, all attempting to lower the cost of care. The most significant of the subsequent laws passed was Chapter 224 of 2012. It established the Health Policy Commission, which was charged with holding the annual increase in healthcare costs in Massachusetts to about 3%. In my estimation, Chapter 224 in 2012 was as important as Chapter 58 in 2006 (Romneycare), because it not only sought to improve costs and care delivery by creating the Health Policy Committee, but also established an agency that would produce the data necessary for wise policy decisions. It was a complex law, so I will let Google’s AI give you a summary:
Enacted on August 6, 2012, Chapter 224 of the Acts of 2012 is a landmark Massachusetts law officially titled “An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation”. It was designed to control the growth of healthcare spending following the state’s 2006 universal coverage law.
Core Objectives
The law’s primary goal is to bring the state’s healthcare spending growth in line with the growth of the overall economy (the Potential Gross State Product). Key strategies include:
- Cost Growth Benchmark: Establishing a first-in-the-nation statewide target for sustainable growth in total healthcare spending.
- Alternative Payment Methodologies (APMs): Moving away from “fee-for-service” payments toward value-based models like global payments or bundled payments to incentivize efficiency.
- Transparency: Requiring providers and insurers to provide patients with price estimates for procedures within two working days.
New State Agencies
Chapter 224 created two major independent agencies to oversee the healthcare market:
- Health Policy Commission (HPC): Monitors the healthcare market, sets the cost growth benchmark, and conducts “Cost and Market Impact Reviews” for major changes like hospital mergers.
- Center for Health Information and Analysis (CHIA): Functions as the hub for healthcare data, managing the All-Payer Claims Database (APCD) and publishing annual reports on the performance of the state’s healthcare system.
Key Provisions & Reforms
- Accountable Care Organizations (ACOs): Promotes the certification of ACOs and Patient-Centered Medical Homes (PCMHs) to better coordinate care.
- Wellness and Prevention: Created the Prevention and Wellness Trust Fund and established tax credits for small businesses that implement qualified wellness programs.
- Workforce Development: Expanded the scope of practice for nurse practitioners and physician assistants to bolster the primary care workforce.
- Health IT: Set a goal for all providers to implement interoperable electronic health records (EHR) connected to a statewide health information exchange (HIE).
- Medical Malpractice: Introduced reforms such as a “cooling off” period and disclosure requirements to reduce litigation costs.
Those were grand objectives, and I was delighted when, as CEO of Atrius Health, I was offered a seat on the Health Policy Commission’s Advisory Board. I soon became frustrated with the Commission’s slow progress, but I remained on the advisory committee until I retired. As I followed the process, I realized that the goal of containing costs was focused on insurance payments in a way that allowed the payers to favor some practices over others. It worked somewhat like a salary cap in pro sports, where heavy hitters get more of the salary pie. The heaviest hitter in our market at the time was Partners Health Care, and smaller practices and hospitals with less political clout would get less in the roll-up to the final number. I don’t know if that is how things work now, but I do know that the objectives of holding down costs and moving away from FFS payment have not been successful. I will let Ms. Wolf describe the situation now:
Health care costs have also ballooned in the last 20 years, especially after the pandemic, affecting the budgets of employers, municipalities, and households. From 2023 to 2024, total health care expenditures per person in Massachusetts increased 5.7 percent. That’s the fourth year in a row the state exceeded the benchmark officials have set for the rate at which those costs should grow, which was 3.6 percent, according to analysis by the state’s Center for Health Information Analysis.
When good intentions aren’t realized, it is easy to be frustrated and for efforts to lose momentum. The last dozen or so years since I retired have been frustrating for many of those who are handed the bills resulting from the failures of Chapter 224. As Ms. Wolf describes:
Both employers and employees are feeling the burden. Small- and mid-size employers had premiums reach an average of $685 and $697 per member per month, respectively, according to the analysis.
During a recent hearing on health cost trends, Retailers Association of Massachusetts president Jon Hurst said small businesses are suffering under the individual health insurance mandate, a pillar of Romneycare.
“As we have stated for many years, small employers need fairness and help on controlling health care and insurance costs,’’ Hurst said in written testimony.
Apparently, the Fanuel Hall event was quite the party. All the governors spoke, as did many of the other key contributors, who moved hope of better care for everyone from a dream to a temporary achievement. Perhaps when we look back at what happened, how a bipartisan effort gained some success is as important as celebrating what was accomplished. Mitt Romney, who could be a reluctant progressive when the political environment favored progress, and then claim to be a staunch conservative when that was a fit for his ambitions, used his speech to celebrate the bipartisan process. Again, Ms. Wolf’s description.
Romney, who served as governor from 2003 to 2007, said during the ceremony that passing health reform was only possible because politicians from across the ideological spectrum were willing to bury old disagreements and the pressure for reelection.
“Now having spent six years in Washington, I have a greater appreciation for what we did here,’’ said Romney, who served as senator from Utah from 2019 through 2025.
I would note that when I asked Google AI what Romney’s proposed platform on healthcare had been when he ran for president in 2012, the answer I got was:
During his 2012 presidential campaign, Mitt Romney pledged to repeal and replace the Affordable Care Act (ACA), aiming to shift control from the federal government to states and increase market-based competition. His platform emphasized giving states authority over health insurance, converting Medicaid into block grants, privatizing Medicare through “premium support,” and allowing insurance sales across state lines.
I always thought that he missed a great opportunity to build on what he had started in Massachusetts. With Massachusetts as the best example, it has always been my sense that progressive states can be “beta sites” to test the effectiveness of potentially innovative healthcare policies, but what is learned must then be made available to all by action at the federal level, which is what happened when Romneycare provided an impetus for Obmacare. It would have been wonderful if, at the 20th-anniversary celebration of Romneycare, we could have used the moment to celebrate continuing progress, but, as Ms. Wolf declares, that is not the reality we anticipate.
Looking ahead to the next 20 years, health care leaders and advocates worry about a growing number of uninsured people. In addition to cost increases and subsidy reductions, more than 200,000 low-income Massachusetts residents are expected to lose coverage through MassHealth, the state’s Medicaid insurance, in the next few years because of federal changes.
One thing I know about Massachusetts is that there has always been a core of people with progressive ideas who are willing to work for distant goals. Ms. Wolf finishes with a glimmer of hope coming from those good souls who will not quit in the face of a dismal short-term national outlook.
Health advocacy groups including Health Care For All are ramping up efforts to limit the number of people who are kicked off the insurance for procedural reasons, Suzanne Curry, the organization’s director of policy initiatives said in an interview.
Curry said Massachusetts is still one of the best-prepared states to handle the upcoming uncertainty.
“I’m feeling really good and really happy that I’m in Massachusetts,’’ she said. “We have had a consistent dedication and commitment from leaders through different administrations, through different legislatures, to maintain health coverage.’’
Boston is blessed with two excellent NPR outlets, WBUR and WGBH. Martha Bebinger has been the healthcare reporter at WBUR for many years. Many of her reports are uploaded to the national public radio network. She also writes regularly for the newsletter published to WBUR subscribers. While I was in a leadership position, I had frequent conversations with her, and I have quoted her on occasion in these notes. Martha was “the program” at my retirement celebration. After a general social hour filled with hugs and some tearful “goodbyes,” she and I ascended to the dias, where she “interviewed” me about what we had done so far to improve healthcare in our journey toward the Triple Aim’s aspirations and what I thought the future challenges would be. This week, Martha also wrote about the twentieth anniversary of Romneycare in an article entitled “20 years after passing nation-leading health care law, Mass. braces for new challenges.” Some of her numbers are a little different than the ones in Ms. Wolf’s piece in the Globe, and she adds some additional data, but the message that we have a problem is the same in both, as Martha applies her long experience to the analysis of the moment. She begins:
In early 2006, roughly 530,000 Massachusetts residents did not have health insurance. Most of these adults and children did not have a regular doctor. Many waited until they were very sick before seeking medical care. A fund that covered emergency room and other costs for the uninsured had ballooned to $1 billion.
That year, state legislators passed a landmark law designed to fix those problems by providing near-universal health coverage for residents. Twenty years later, Massachusetts has among the lowest uninsured rates in the country. Its Health Care Reform Act inspired the sweeping federal overhaul known as the Affordable Care Act…
So far, so good, and she raises a great question: whether we can apply what was learned in 2006 to improve this fraught moment when we see the gains of the past slipping away. She continues with a little background that was left out of the Globe report:
…And many are wondering whether that period of negotiations and compromise can offer lessons for solving urgent health care challenges at a time of intense political polarization.
Pardon my extensive copy-and-paste writing, which produces some redundancies, but I want to continue without eliminating any of the description of the 2006 landscape that Martha offers. Please note that the lawmakers and the executive branch of the state government were responding to intense demands from a well-organized, harmonious public voice.
The 2006 law was the product of an unlikely coalition of elected officials, business, hospital and religious leaders, and insurers, forged in response to political, financial and moral pressures.
The federal government had threatened to stop paying its share of the $1 billion bill for uninsured care from hospitals and health care centers.
The Blue Cross Blue Shield of Massachusetts Foundation had issued a series of reports modeling options for expanded health insurance coverage and invited top lawmakers to speak at summits attended by hundreds of health care leaders.
Consumer advocates and religious leaders added to the pressure with a ballot question that demanded action to cover the uninsured.
“From all across this commonwealth, we will rise up, take health care reform to the polls, but hold you accountable,” said Rev. Hurmon Hamilton, then-president of the Greater Boston Interfaith Organization, in an address to lawmakers in early 2006.
On April 12 of that year, after months of tense bargaining and stalemates, the governor at the time, Mitt Romney, a Republican, sat on a stage at Faneuil Hall, flanked by the late Democratic U.S. Sen. Ted Kennedy and the state’s top Democratic leaders, and signed a set of precedent-setting health care reforms into law.
The new law made health insurance mandatory for individuals, fined some employers who didn’t provide it and created subsidized health plans for low- to moderate-income residents.
It was an amazing moment. What is sad is that after the passage of the ACA, we have been “slip slidin’ away” from the moment initiated by the action of so many people who believed in the imperative of equity in healthcare. After a testimony from a consumer who got care from the miracle of 2006, Martha gives us some more data followed by an understatement and an explanation that defines the work of the future.
Studies show access to health insurance improved residents’ sense of health and wellbeing, reduced preventable hospital visits and led to 320 fewer deaths a year. Some have argued the law didn’t go far enough toward creating a system of universal health care and has not contained health care spending.
“Giving health insurance to people makes them much better off,” said Larry Levitt, executive vice president for health policy at KFF, a health care research group. “But it doesn’t necessarily lower the overall cost of health care. When you give people health insurance, they use more health care, not less.”
Mr. Levitt is a long-time advocate for healthcare policies that aim to deliver universal, high-quality care at a sustainable cost. After another case report, Martha returns us to the realities and failures of this moment:
But in more recent years, the state has failed to meet its targets. In 2023, the benchmark was 3.6% while health care spending increased 8.6%. In 2024, the most recent year with data available, the 5.7% rise was more moderate but still strained individual, company and government budgets…Massachusetts also faces new federal pressures. The Healey administration expects to lose $3.5 billion in federal health care funding every year once Medicaid cuts approved by the Republican-led Congress are fully in effect in 2028. Roughly 250,000 residents are expected to lose health coverage because of new Medicaid work requirements. One recent report by the Robert Wood Johnson Foundation shows a larger percentage of Medicaid recipients are at risk of losing coverage in Massachusetts than in any other state.
Martha knows the score. In my experience, she has always been a straight shooter, even when her assessment of reality would not be well received. She was writing last weekend in anticipation of the “celebration:”
That grim prediction has demoralized many in Massachusetts’ health care sector who do not want to see insurance coverage rates slide backward. Some are asking, as they mark this anniversary, whether the state’s elected, business, health care, consumer and religious leaders come together again to tackle pressing health care threats.
So, I will leave you with a broadened version of Martha’s final question. Can we reproduce the cohesion and the will of the miracle of 2006 that brought together elected, business, health care, consumer, and religious leaders? And I would add the majority of the voting public to this fantasy coalition that would be intent on tackling the pressing health care threats to our nation.
The Ice Is Gone
Earlier this week, my drone-wielding neighbor Peter Bloch got into his kayak and did a little underwater photography to reveal the marvels of melting ice that most of us never see. I recommend that you spend the time, less than 2 minutes to see what Peter offers. To my eye, some of his scenes look like the “moonscapes” sent back to Earth from the crew of Artemis II.
If you are in Boston on Monday, it’s going to be a chilly 130th Boston Marathon. The first time I tried to finish the race, 49 years ago, the asphalt temperature was over 90 degrees. I foolishly went out with the goal of breaking 3 hours and died at 18.5 miles on one of the Newton hills. In October that year in New York, on a less steamy day and benefiting from lessons learned in the heat at Boston, I was able to finish the first of about 50 marathons. Over the years, I would occasionally get too enthusiastic and run out of gas prematurely, but I did finish Boston 22 times, and several of those Bostons were with my oldest son.
My son’s best time of 2.57:02 came at Boston when he was in his mid-twenties. My best time of 2:57:57 came in 1978 at age 33, when I qualified for Boston at a marathon in Lowell. Six weeks later, still not completely recovered from the Lowell race, and on a chilly day like they are predicting for this year’s marathon, I finished Boston for the first time with a 3:07:16.
My joke with my son is that he holds the family record for best time in the 20s. I hold the family record for the best time for over thirty. We are competitive. Those were the days. With great effort, I will try to walk four miles on this Marathon Monday. There won’t be crowds lining the roads on my route by the lake, but I will still enjoy the same sense of effort that I enjoyed on those heady marathon days so many years ago. I always ran with a goal. My goal for Monday is to do my four miles in under two hours.
I hope to “get on the water” soon. I was able to get our “dock guy” to assemble our dock for the summer. It was good to get the eight-foot sections out of our yard so we could begin our spring clean-up and get all the boats in the water. We have enjoyed a couple of evenings this week when the temp was still in the low 70s, which allowed us to sit on the dock in the evening looking for the loons. The loons are back. Daffodils are trying to appear. Good times lie ahead. I hope that your weekend includes some renewing activity in warm spring air.
Be well,
Gene
