(Hush Naidoo Jade Photography on Unsplash

THANKS TO THE Legislature’s unwillingness to update its oversight powers, the state Health Policy Commission increasingly resembles a group of neurologists — highly skilled at diagnosing and describing problems, but quite limited in their ability to do anything effective about them.

That limitation is understandable in the case of neurologists, whose domain includes conditions like ALS and Parkinson’s disease, for which managing symptoms and improving quality of life, not a cure, represent the best standard of care currently available. For the Health Policy Commission, the inability to do something about problems it identifies is a shortcoming that could be addressed – if there were the legislative will to give HPC the needed authority to do so.

The reality of the HPC’s limitations was on full display at its April 16 HPC meeting, where two issues dominated: what to recommend about the proposed Mass General Brigham-CVS Minute Clinic affiliation (which I’ll address in a subsequent piece) and where to set the 2027 state health care spending benchmark.

Since its creation in 2012 as part of legislation aimed at containing health care costs, one central function of the Health Policy Commission has been to set an annual benchmark for health care cost growth in the state. This ritual of establishing a spending cost target that providers and payers should not exceed has come with an uncomfortable truth: The HPC is essentially powerless to enforce its annual edict.

At last month’s meeting, the HPC board set the benchmark for the coming year at what has become its customary per capita growth rate of 3.6 percent.

More difficult to convey is the palpable sense of resignation in the room — a resignation made all the more striking given that health care unaffordability is now the dominant theme in virtually every discussion of health care in Massachusetts.

The benchmark outcome was no surprise. The HPC has essentially been on autopilot in landing on the 3.6 percent figure since the commission was created nearly 15 years ago. The growth rate is tied to state finance agency economists’ predictions of nominal economic growth — a figure that has barely budged over this period. The only exception came during the second five-year period of the HPC’s existence, when state law required the benchmark be set 0.5 percent below projected economic growth, briefly landing it at 3.1 percent.

Board member and economist Keith Ericson tried to put some of the frustration in context. He shared data at the meeting — posted on his own website — showing that Massachusetts does not really have an “unsustainable” health care spending growth problem when viewed through a macro lens. As a share of state GDP, health care spending was essentially flat from 2013 to 2023 (10.9 percent vs. 10.7 percent). As a share of median household income, it actually fell, from 11.7 percent to 10.5 percent over the same period.

Ericson was careful to note that these aggregate trends don’t mean we lack an affordability problem. Growing numbers of individuals and families are carrying heavier cost-sharing burdens under commercial insurance.

Some are facing acute financial hardship following the Trump administration’s decisions to end enhanced subsidies for health plans purchased through the state Health Connector. And certain providers with substantial market leverage extract supranormal prices — a form of economic waste — that raises total spending without producing better care.

Still, I’m not as sanguine as Ericson appeared to be about sustainability. Federal Medicaid cuts are scheduled to grow starting next year. Commercial premiums for many are already rising at double digits. If a recession arrives, the sustainability argument dissolves quickly. And families struggling with eye-popping premium increases gain little comfort knowing that median incomes have also risen. Survey households around the Massachusetts median — roughly $105,000 in 2024 — and ask whether rising health care costs feel sustainable. I doubt many would say yes.

Ericson concluded that, given these macro findings, he would not push to slow spending growth below the usual benchmark rate or intensify penalties for individual providers who exceed it. His preferred interventions: direct subsidies for families who genuinely can’t afford care, and policy tools targeting providers who extract supranormal prices.

I support those interventions, too. But it feels wasteful to simply accept — and bake in — all of the existing inefficiency in the system. Ericson’s logic effectively says, if the waste was there in 2013 and hasn’t grown faster than the economy overall, we shouldn’t worry too much about it. That’s a difficult argument to accept when the question is the overall health and financial well-being of Massachusetts residents.

That’s why I found myself much more persuaded by Umesh Kurpad — the only HPC board member who refused to vote for the 3.6 percent benchmark. In so doing, Kurpad, the former CFO of 32PointHealth, pointed out that Massachusetts health care costs roughly 15–20 percent more to deliver than the integrated care model used by Kaiser Permanente, one of the country’s largest non-for-profit health plans, which has been operating for over 80 years. His question: Why can’t we reorient our system to operate more like that?

Symbolically, Kurpad seems to be saying the benchmark should be zero, or even negative — not because that’s immediately achievable, but because setting it at 3.6 percent sends precisely the wrong signal. It relieves pressure on the system to reorganize and become more efficient. It tells providers and insurers that the status quo is acceptable.

That critique matters. Kaiser’s population health, mortality, and equity outcomes — particularly in its operations in Northern California and Colorado — are as strong as anywhere in the country. The model works. Whether it can be replicated at the scale of an entire state is a longer conversation. But Kurpad is right to insist that we at least ask the question rather than simply ratifying the current arrangement year after year.

And that, I think, is the source of the frustration I sensed in the room when the vote was taken. Board members and staff seemed to understand that setting the benchmark at 3.6 percent — again — would have no meaningful effect on how providers and insurers negotiate contracts, no consequence for market dysfunction, and no impetus for health care redesign.

It’s a bit like a neurologist seeing a patient with worsening dementia, writing it up carefully in the chart, and wishing them the best on the way out.

Paul Hattis is a senior fellow at the Lown Institute and co-host of the monthly Health or Consequences episodes of The Codcast.