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IDEAS

How Massachusetts became a national leader on health care — and how it can lead again

The state was the first to provide near-universal coverage. But now there’s more to be done.

At Faneuil Hall in 2006, Governor Mitt Romney signed his health care bill.
At Faneuil Hall in 2006, Governor Mitt Romney signed his health care bill.Ryan, David L Globe Staff

Four years before the Affordable Care Act became the law of the land, Massachusetts governor Mitt Romney signed into law massive health care coverage expansions, subsidized by federal funding, to create near universal coverage in the state. That law became the model for the ACA, which when passed, allowed Massachusetts to further expand its healthcare coverage. Today, only 3.5 percent of the state’s population is uninsured.

“We were already pretty good before the health care law. But a large part of our success is our first-in-the-nation health care reform, which remains the strongest in the nation,” says Jonathan Gruber, a health care economist at the Massachusetts Institute of Technology and ACA architect whose models helped inspire Romney’s legislation.

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Massachusetts has been a clear leader when it comes to health care coverage, and as a result, outpaces other states in health care outcomes. But it has taken a village of health care policymakers, economists, practitioners, community leaders, and legislators to create an insurance coverage system that not only works, but that also rises above partisan acrimony.

Massachusetts “had a Republican governor, Democratic speaker of the House, and a Democratic president in the Senate,” said Michael Zinner, professor of surgery at Harvard Medical School and surgeon-in-chief at Brigham and Women’s Hospital. “And they all wanted a bipartisan solution to be able to lower the uninsured rate.”

Everyone had skin in the game, said David Seltz, executive director of the Massachusetts Health Policy Commission, the state’s medical costs watchdog. “A whole range of stakeholders, hospitals, physicians, health plans, business community, community groups, religious organizations, public health, consumer advocates . . . in the development of reform, their input is sought.

“But it’s not just about getting a bill passed, but how to build and nurture a coalition that says, ‘well, we are all in this together, we share in the success and we share in the failures,’” Seltz said.

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How did the state manage to be almost radically bipartisan when it comes to health care, or at least sensibly pragmatic? Urban Institute fellow and private health insurance expert Linda Blumberg says that the appeal to both parties was the reforms’ “middle of the road approach.”

Another ingredient in the successful overhaul, according to John E. McDonough, professor of public health practice at the Harvard T.H. Chan School of Public Health, is Massachusetts’ “own talent pool of people, many of whom have been working on healthcare issues since the 1980s and who have, due to various and varied positions inside the health care system, stayed on the challenge of improving access as much as possible regardless of their different positions over, literally, 35 years.”

Being data driven seems to be another hallmark of Massachusetts’ evolving health care system; what Seltz terms a “commitment to using data.” The Bay State has robust data assets, according to Seltz, that put it at an advantage.

“I think we’re probably the leading state in the country in terms of our understanding of the health care system,” says Seltz. “The costs, the barriers, and the challenges. That’s important because it provides a basis to move beyond anecdotes and perception and to be able to start a conversation, by asking, ‘What does the data tell us? What does the evidence tell us?’”

But that doesn’t mean all is perfect. About 22 percent of adults in Massachusetts have trouble paying medical bills, according to a new report by Washington-based consultancy Altarum, with many complaining that high-deductible health plans come with steep out-of-pocket costs.

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“We constantly have to work towards improvement . . . We haven’t solved all the problems,” says Gruber. “True reform is continuous and happens over long stretches of time.”

Expanding coverage was just the first step, Blumberg says. “First, coverage has to be in place. And then from there, you can talk about where we can create efficiencies in the health care delivery systems and reduce costs.”

Making inroads on affordability — lowering co-pays and providing value-based alternatives to traditional yet unchecked fee-for-service payment systems, while monitoring for inappropriate care — seems to be the way forward, according to experts.

Those who spoke to the Globe all agree that while costs are problematic, they’re not impossible to bring down. “There are ripe opportunities to be able to reduce unnecessary costs in the system,” says Seltz, citing as an example providing more timely care so that people don’t seek out the emergency department because they can’t reach their primary doctors. “An emergency department visit is probably around five to six times more expensive than a primary care doctor’s office.”

And yet, some seek greater overhauls, such as Robert Kaestner, research professor at the University of Chicago’s Harris School of Public Policy who believes the state should “encourage provider competition by making sure that hospital and provider consolidation isn’t too great.”

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Pioneer Institute senior fellow in health care Barbara Anthony agrees, saying that there’s a lot of market power in the hands of a few players.

“There’s only two ways to control prices. You either have a competitive market or you have price controls. No one wants price controls.” That leaves what Anthony referred to as “unscrambling the egg,” which would mean breaking up large conglomerates such as Partners HealthCare, the state’s biggest health care provider, which recently rebranded itself as Mass General Brigham, debuting its new name at a major San Francisco conference on Jan. 13.

And while nearly everyone has access, inequities still exist. “There are pockets in Massachusetts where access is not readily available as it is in the Boston area or major cities,” says Anthony. “We have problems in the rural parts of our state. The access is a problem for people there because their practitioners are not located there, so they have to travel long distances to get to quality providers and programs.”

McDonough says that despite achieving substantial gains over the past 15 years relative to other states, “surprisingly, it turns out that Massachusetts has a great degree of inequality . . . so it is a more targeted effort to go after the pockets of people who are feeling distressed under the current system.”

This inconsistency in the ease of access extends to practitioners. “There are many dentists who won’t take Medicaid patients. We have doctors who don’t take Medicaid,” Anthony says.

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Another area where the state’s performance leaves a lot to be desired is access to behavioral and mental health and drug use disorder services, with many providers refusing insurance for behavioral health at the current reimbursement rates.

“The first thing we have to do for mental health and substance use disorders is raise the rates that we pay to providers for the service. They are extremely low and it’s just forcing people out of the system,” says state senator Cindy Friedman. The second thing, she says, is integrating behavioral health into primary care. “We have to stop carving out mental health. As long as we treat it as a stepchild or a separate piece of health care, it will be so difficult to get to.”

Governor Charlie Baker renewed his pledge for massive healthcare updates in his annual State of the Commonwealth address on Jan. 21. While the governor boasted about the state’s leadership in providing affordable insurance and praised how it handled the opioid crisis in a way that “has set the table for other states” — with state spending on prevention and treatment tripling — he acknowledged that there’s much more to be done and that “our health care system has failed to adapt to the changing nature of illness.”

Last fall, Baker filed a health care reform bill that promised to rein in prescription drug prices and — in an aggressive bid to address challenges related to behavioral health services and substance use disorders — to push providers and insurers to increase spending in these areas by 30 percent over the next three years. The bill also includes provisions to strengthen the state’s mental health parity laws to ensure equal coverage for addiction and mental health.

“At its most fundamental level, our proposal is about nudging caregivers and health plans to put more resources into time, on primary care and behavioral health services, while limiting overall growth in health care spending,” he said, adding that the system should reward clinicians who “invest in time and connection” with patients, as well as offer guidance and support to people dealing with one or multiple chronic illnesses.

Pakinam Amer is an award-winning journalist, former Knight Science Journalism fellow, and a research affiliate of the Center for Advanced Virtuality at the Massachusetts Institute of Technology. Send comments about this story to ideas@globe.com.