MASSACHUSETTS SENATORS are ready to embrace a sea change in the state’s health landscape by forcing far greater focus and spending — on primary care. And in the process, they’re inviting a heavyweight political throwdown with influential hospital systems.
The Senate will vote next week on a bill that would reshape and reinvigorate the strained primary care system, more than doubling the amount of money that goes toward health care’s entry point and incentivizing more doctors to choose the field instead of other, higher-paying specialties.
It’s a long-gestating response to a problem that has been worsening for even longer. Most health experts agree that primary care in Massachusetts is in crisis, with patients routinely stuck waiting months for appointments and many members of the burnt-out health care workforce heading for the exits.
But getting buy-in on a potential solution presents a challenge. The Senate’s proposal aims to significantly increase what insurers and providers spend on primary care without increasing the total amount of spending, meaning that some combination of other sectors like pharmaceuticals and specialty care would essentially lose money. Plus, the House has not given any indication that it’s also ready to tackle primary care overhauls in a quickly closing window this term.
“We absolutely expect that we’ll get pushback from hospital systems and specialty care. We will. We definitely will,” Sen. Cindy Friedman, the architect of the Senate’s bill, told CommonWealth Beacon. “This is a big change. If it happens, it’s a definite shift in how we’re paying.”
Policymakers regularly praise primary care as the linchpin of the system. It’s often designed to be the front door to medical care, allows physicians to develop long-term relationships with patients, and can help control costs by eliminating the need for pricier specialty or emergency care down the line.
Yet primary care’s cracks are increasingly turning into chasms. A new Center for Health Information and Analysis survey published Thursday found that 43 percent of Bay Staters had difficulty obtaining health care in 2025, up 10 percentage points from four years earlier. A report published last year found patients in Boston faced the longest average wait — 69 days — among residents in 15 cities when booking a physical with a new provider.
Investment in the sector is paltry, too. In 2023, only 7 percent of health care spending by commercial insurers went to primary care; a year later, that share fell to 6.6 percent.
The Senate bill would dramatically boost that figure, requiring health care entities to increase the share of their spending that goes to primary care to 15 percent over a three-year period starting in 2028. Once that target is fully realized, the Health Policy Commission would have authority to raise it again, but it could never drop below 15 percent.
A firm minimum spending target, Friedman said, is “the only way you can measure whether there actually is movement and investment.”
The Health Policy Commission, a state organization that monitors and reports on the condition of the health care system, would be authorized under the bill to fine any entity that fails to spend enough on primary care.
“We’ve learned over and over again that without an enforcement mechanism, there’s not really strong incentive to comply,” Friedman said.
Senate Democrats said the bill seeks to increase the ratio of spending on primary care, not overall costs. In other words, senators want to keep the pie the same size but devote a bigger slice to primary care, which means any of the other components would have to cede some ground.
That approach might draw objection from some stakeholders. Health plans signaled frustration Thursday, arguing that even if senators pitch the bill as designed not to increase total spending, the combination of retroactive performance improvement plans and fines against noncompliant entities is not strong enough to force change.
It’s also not clear which industry segment would actually lose out because the bill does not explicitly redirect money away from anyone. Instead, it would be up to individual entities to figure out how to divide their dollars in a way that complies.
The spending target largely reflects the recommendations a state task force made last year after studying the topic in-depth and weighing input from virtually every stakeholder group, including providers, hospital systems, and insurers.
Former governor Charlie Baker twice filed bills, once in 2019 and again in 2022, that aimed to force providers and insurers to increase spending on primary care and behavioral health with a somewhat different mechanism. Both proposals died without receiving votes in the House or Senate.
The idea, Baker said shortly before he left office, “freaked everybody out.”
Today, the climate appears different.
“The crisis that we all have known about is now understood by many more,” Friedman said. “There’s becoming more of a critical mass.”
In addition to shifted spending, the payment model itself would change under the Senate bill. Insurers in most cases would need to pay doctors a flat fee for each patient each month, a change from the fee-for-service system in which providers bill for each visit or procedure. A Senate summary described it as avoiding “nickel-and-dime billing every time a patient walks in the door.”
Other sections of the bill aim to supercharge the shrinking primary care workforce by investing in pipelines that funnel more physicians into the field, and to level the playing field for community health centers, which play a vital role in lower-income areas.
Friedman said some insurers reimburse community health centers only 70 percent as much as MassHealth, the state’s Medicaid program, does for the same services. Under the bill, commercial insurers would need to pay community health centers the same as MassHealth.
The proposal is already raising eyebrows among insurers. Lora Pellegrini, president of the Massachusetts Association of Health Plans, said that although she agrees primary care needs major reforms, the Senate’s approach “will raise costs for employers, consumers, and purchasers of health coverage at a time when affordability remains one of the Commonwealth’s most pressing health care challenges.”
A spokesperson for PhRMA, an industry group representing pharmaceutical companies, declined to comment on the bill.
The biggest variable, at least in the short term, could be the House. None of the Senate’s proposed changes can become law without buy-in from the other chamber, and top House Democrats for most of the term have avoided taking a clear stance on whether they want to pursue primary care legislation.
Under revised legislative rules, lawmakers can negotiate a final bill into the fall and winter but only if each branch approves an initial versionby July 31.
Rep. John Lawn, Friedman’s counterpart leading the Health Care Financing committee and a fellow member of the primary care task force, did not respond to a CommonWealth Beacon inquiry Thursday. A spokesperson for House Speaker Ron Mariano said only that the House would review the bill once it arrives.
So for now, the debate will be limited to the Senate.
“There’s something for everybody to like,” Friedman said of the bill, “and something for everybody to be cranky about.”
