(Illustration by Gerd Altmann via Pixabay)

WEDNESDAY IS THE Massachusetts Health Policy Commission’s annual Health Care Cost Trends Hearings, when we hear remarks from state leaders and questions posed by members of the commission to panelists who represent various constituencies in the Massachusetts health care ecosystem. 

Massachusetts health care over the years has tended to resemble the “Perils of Pauline” — with one train or another barreling down the tracks toward us. Somehow, however, the system has always survived more or less intact.    

This year, things seem quite different, and the hearings come as the well-being of the health care system is under a greater series of threats than any time in recent history. A confluence of challenges points to very hard times for the Massachusetts health care system.   

Here are the main areas of concern.   

System and Family Unaffordability: During the time since the HPC came into existence in 2012, we have not witnessed the sort of health care spending and premium growth that we are seeing right now. Per capita state spending growth continued its three-year rise above the 3.6 percent benchmark, with the most recent measure more than double that target, at 8.6 percent.  

That growth is being driven by hospital and pharmaceutical spending, and is now reflected in double-digit premium increases across all forms of commercial insurance. This fall, the Division of Insurance, after rejecting even higher rates, approved an average increase of 13.4 percent for the individual and small group market for 2026. Our state’s own insurance plan for state workers and retirees, overseen by the Group Insurance Commission, had to seek a $250 million bailout for the fiscal year in June because the upward trend in medical care spending and use of the GLP-1 weight loss drugs by plan beneficiaries had blown away actuarial estimates for pharmaceutical utilization. In all, more than 40 percent of residents report difficulty in paying for health care. 

Upcoming Growth of the Under- and Uninsured: Ever since passage of the 2006 health care reform law known as Romneycare, Massachusetts has not seen significant yearly increases in the number of uninsured in the state. But passage earlier this year of the “One Big Beautiful Bill Act” (House Resolution 1), which will trigger over $1 trillion in cuts to health and human service programs nationally, especially for Medicaid, over 10 years, will likely result in about 10 million Americans losing Medicaid coverage over the decade.  

A Blue Cross Blue Foundation of Massachusetts study estimates that the number of uninsured in Massachusetts will increase by more than 50 percent based on this law alone, which adds new work requirement and paperwork burdens for maintaining Medicaid coverage and new verification requirements for buyers of subsidized plans on Affordable Care Act exchanges.  

Many more are now expected to drop ACA coverage, sold here through the Health Connector, if enhanced ACA premium subsidies, set to expire on December 31, are not renewed—now even more likely to occur as the move to reopen the federal government came without any deal to maintain them. Add to this a good number more who obtain coverage through the merged market or through employers and are healthy—who may either buy plans with more cost sharing or forego coverage altogether.  

Hospitals: We are accustomed to the reality that the story of Massachusetts hospitals, like those in other states, has become a tale of two cities. “Emerald City” providers such as Mass General Brigham, Boston Children’s, and Dana-Farber are secure, while a growing set of “Gotham City” providers, such as Baystate Health and Tufts Medicine, are financially challenged and in need of state support.  

Medicaid cuts are especially threatening to the “Gotham City” group as they face increasing numbers of uninsured patients. In late September, Gov. Healey and the Legislature approved $200 million in supplemental payments to hospitals, though this is no way represents a long-term fix for the most challenged in the group. 

Even the wealthier providers, however, despite net asset increases fueled by investment gains, are challenged to stay financially stable right now. Well-heeled Mass General Brigham recently announced staff layoffs and other cuts to protect their bottom line.  

Recissions and planned future cuts to the National Institutes of Health budget by the Trump administration are an added serious threat to our “Emerald City” providers, who are among the top recipients of federal research in the nation. Added to this group’s challenges is that the state’s biopharma industry is now shedding jobs and failing to attract much new investment. This will likely have spillover effects on our major teaching hospitals, which often gain revenue from contracts with the biopharma industry. 

Community Health Centers: The state’s proud network of community health centers are triple losers from President Trump’s policies.  Attacks on immigrants will eliminate Medicaid even for those with legal status. Many others who rely on subsidized Health Connector plans will become uninsured patients. Meanwhile, changes to the federal drug purchasing program that allow health centers to gain some margin by reselling drugs they obtain at a discount is slated to be cut back, threatening this important revenue stream that allows many to get to breakeven on operations.   

The Legislature, mindful of these cuts, allocated $35 million to them directly, plus a share of the $77 million identified for the Health Safety Net Trust Fund. Even with this help, the future is very uncertain for a number of health centers. 

Primary Care: Primary care remains broken as we await policy recommendations from the state commission established to address inadequate availability, payments, and burnout among those in this sector. The crisis is moving some to unionize, while others are moving into concierge or direct primary care practices. 

Meanwhile, big for-profit companies remain active trying their own approaches to getting richer through primary care. Optum-owned Atrius Health is acquiring Acton Medical Associates to gain market share, while CVS and Mass General Brigham decided there is money to be made by joining together to turn Minute Clinics into primary care outlets in 27 locations with what appears to be MGB-branded solo nurse practitioners holding down the store.  

It remains unclear whether any of these developments will ameliorate the primary care shortage that keeps getting worse. 

Insurers: Finally, our dominant non-profit insurers, Blue Cross Blue Shield and Point 32, a duo we expected to be stable in good times and bad, have been losing significant money these past few years. There is mounting worry that Point 32’s growing financial hole and diminishing reserves may trigger a buyout proposal from a national for-profit. This would be a cataclysmic moment for Massachusetts’s mostly non-profit insurance system. And Blue Cross, which saw $400 million-plus in losses last year, and expects a negative operating margin of $700+ million in 2025, may not be immune from wanting to explore a conversion or a merger to strengthen its capital base. 

When you put all of this together, the threats to the public health, health care provider, and health care training ecosystem in Massachusetts are as serious as any we’ve seen in decades.  

It will be one thing for those speaking at this week’s Health Policy Commission hearings to tee up the serious, multifaceted challenges we’re facing. The real test will be charting a course of action that lays out a plan for what to do about it all. 

Paul Hattis is a senior fellow at the Lown Institute.