(Image by REDQUASAR via Pixabay)

I DID NOT come to the Legislature as a health care policy expert. I came as a witness.

I grew up in the Mission Main public housing development, as Boston grappled with school desegregation and the expansion of the Longwood Medical Area just blocks away. For families like mine, those changes shaped whether we were seen, heard, and treated with dignity when we needed care.

Health care in the 1970s through the 1990s was too often fragmented, inaccessible, and unequal. My mother and her peers did not accept that. They organized, challenged institutions to listen, and taught me that access begins in community.

That lesson stayed with me when I had the honor of representing the 15th Suffolk District and chairing the committees on Public Health, Health Care Financing, and Ways and Means though my 16 years as a member in the Massachusetts House of Representatives. As we mark 20 years since the enactment of the landmark health care law often referred to as Chapter 58, I believe we should be clear about what made that 2006 law so important: It was the moment the Legislature decided that access to health coverage could not be left to chance.

Chapter 58 mattered because it did more than expand insurance. It built a durable framework for coverage by combining Medicaid expansions, subsidized private plans, insurance market reforms, employer participation, and the Health Connector into a workable strategy.

Just as important, it reflected a simple but powerful belief: Government had to lead, but employers, insurers, providers, and individuals all had a role in making the system work.

That was a profound shift. Before Chapter 58, too many working families lived one illness away from financial crisis, even in a state with world-class hospitals and extraordinary medical talent. The law moved Massachusetts closer to the principle that coverage should be the norm, not the exception. It helped make our Commonwealth the national leader in insurance coverage and showed the country that a legislature, working seriously and persistently, could take on a problem many believed was too large and too politically difficult to solve.

But the significance of Chapter 58 was never just in the coverage numbers. It also changed how the system thought about people. It pushed institutions to pay greater attention to outreach, enrollment, language access, and the practical barriers that keep families from care even when programs exist on paper. It strengthened the idea that equity and access are not abstract values. They require institutions to meet people where they are and to recognize that trust is part of the health care infrastructure.

Over time, that helped broaden the ways organizations across the system engaged community. In the commercial market and in Medicaid, there has been greater recognition that care cannot be designed only from the top down.

Community-based organizations, local advocates, neighborhood leaders, and frontline providers all play an essential role in helping people understand their coverage, navigate the system, stay connected to care, and address the realities that shape health long before someone enters an exam room. That has been one of Chapter 58’s quieter achievements. It created the conditions for a more inclusive and more community-responsive approach to care.

Still, taking stock of Chapter 58 requires honesty. The law solved an enormous part of the coverage challenge, but it did not solve everything. Having an insurance card does not always mean being able to find a primary care doctor, afford out-of-pocket costs, access behavioral health services, or move easily through a system that remains too complicated and too uneven.

Too many families still experience delay, confusion, and financial strain. Too many communities still experience disparities in outcomes and in the quality of their interactions with the system.

That is where the next phase of reform must focus.

First, affordability has to be treated as an access issue. If premiums, deductibles, co-pays, and prescription costs continue to rise faster than family budgets, then coverage loses some of its promise. Protecting the gains of Chapter 58 means making sure people can actually use the coverage they have.

Second, we need to rebuild the front door to care. Primary care, behavioral health, and the workforce that supports both are under strain. When people cannot get a timely appointment, when mental health care is out of reach, and when providers in community settings are stretched too thin, the system stops feeling accessible no matter what our coverage rate may be.

Third, equity must be treated as a design principle, not an afterthought. That means continuing to strengthen language access, culturally responsive care, and partnerships with organizations that know their communities and have earned trust. It means creating more room, in both Medicaid and the commercial market, for models of care that reward coordination, prevention, and meaningful engagement with the people most at risk of being left behind.

Chapter 58 remains one of the great legislative achievements in Massachusetts history. It gave hundreds of thousands of people a more secure place in our health care system and challenged that system to become more responsive to the people it serves.

The task now is not to move beyond Chapter 58. It is to finish the work it began: To make care not only covered, but affordable; not only available, but accessible; and not only technically equal, but genuinely equitable.

The anniversary of Chapter 58 should be more than a celebration. It should be a commitment to finish what the Legislature began.

Jeffrey Sánchez is principal of Sánchez Strategies, a senior advisor at Rasky Partners, a department associate at the Harvard T.H. Chan School of Public Health, and co-founder of the Massachusetts Health Equity Compact. He served in the Massachusetts House of Representatives from 2003 to 2018.