Muhammad Ali. (Photo via Wikipedia by Boxing Illustrated Magazine/Champion Sports)

WHEN I LAID OUT my concerns in advance of last week’s annual hearings on cost trends held by the state Health Policy Commission, I suspected many across our health care ecosystem shared them. The hearings confirmed that.

Speaker after speaker voiced anxiety about the same issues: the harmful impact of Trump administration policy changes combined with passage of the One Big Beautiful Bill Act; the growing affordability pressures facing families, employers, and state government; the likelihood of increases in both the uninsured and underinsured; the return of double-digit premium hikes; and the precarious financial position of many hospitals, community health centers, and nonprofit insurers. 

My hope then—and still—is that we not only sound the alarm on the dire state of things, but can begin to collectively chart a course of action that lays out a plan for what to do about it all. But anyone listening last week for a clear sense of direction would have been disappointed. While there was general consensus at the hearing that it can’t be business as usual, the ideas offered up for what to do about it were piecemeal. There was no coherent roadmap, no shared strategy, and certainly nothing resembling a statewide plan. 

The day opened with Attorney General Andrea Campbell, the lone elected official to speak. She noted the legal battles that her office is involved in with other state attorneys general, fighting against the Trump administration. She enumerated a series of conflicts: efforts to restrict immigrant rights, threats to universities’ federal research funding, actions designed to limit or eliminate access to gender-affirming care, and the battles to continue SNAP benefits during the shutdown. 

Her message was energetic, forceful, and morally clear. But like most presenters that day, despite expressing deep worry about health care affordability, she did not offer concrete solutions.  

What she did offer, though, in a positive note of encouragement about our collective strength and resilience, was an unexpected reference to Muhammad Ali—praising him as someone who consistently punched above his weight, just as Massachusetts has tried to do in health policy and other areas.  As an Ali enthusiast since childhood, that comment caught my attention. So let’s consider the rest of what unfolded at the hearing through the lens of some of The Greatest’s more memorable lines. 

“Float like a butterfly, sting like a bee.” 

This year marked the first time pharmaceutical companies and pharmacy benefit managers (PBMs) were required to submit written testimony and for a select group to answer questions from Health Policy Commission members. A senior executive from Eli Lilly and a vice president from Optum took the hot seat. 

Pharma companies and PBMs often glide through policy discussions with a polished narrative. Pharma emphasizes innovation, miracle drugs, and breakthroughs. PBMs describe themselves as indispensable negotiators, creating savings for employers and consumers. Their public personas “float” lightly above the messy realities of pricing, profit margins, and opaque contracting. But history reminds us that these companies can sting hard. Whether through monopoly pricing, strategic patent games, or non-transparent rebates and fees that warp incentives, both industries have figured out how to extract tremendous profits from a system they claim to be helping. 

Consider Lilly. Their representative highlighted the company’s new oral GLP-1 weight loss drug, recently approved by the FDA, which will be priced around $150 per month—dramatically less than the current injectable versions costing thousands per month. He clearly hoped for praise. What he did not highlight was that this accelerated approval came after the company struck a deal with the Trump administration involving tariff relief and expedited FDA review for this drug — likely leading to a 2026 launch date.  

Optum’s witness spoke earnestly about negotiating lower prices for certain brand-name drugs, but carefully sidestepped questions about rebate transparency. She showed no interest in discussing how PBM practices contribute to inflated list prices designed to accommodate the rebates PBMs demand. Nor did she acknowledge the well-documented steering of patients to PBM-owned pharmacies, often at the expense of independent community pharmacies.  

“Don’t count the days, make the days count.” 

The day’s standout voice belonged to Michael Levine, director of the state’s Medicaid program, MassHealth. His presentation was a refreshing blend of candor and practicality. Levine described the central challenge ahead: navigating the implementation of new work requirements and administrative hurdles created by the sweeping bill passed this summer, dubbed by Trump the One Big Beautiful Bill Act. These changes threaten to push eligible residents off the Medicaid rolls not because they fail eligibility tests, but often because they cannot easily show that they are exempt from work requirements or meet other paperwork demands. 

Levine outlined two major strategies to prevent unnecessary loss of coverage. First, the state will maximize auto-renewals, drawing on an array of state data sources to verify eligibility without requiring beneficiaries to submit new paperwork. Second, the administration plans to again partner with Health Care For All, replicating their 2023 outreach initiative to help residents complete required documentation.  

His message was clear: The period between now and January 1, 2027—the date when new rules take full effect—must be used to protect as many eligible people as possible. Levine embodied Ali’s dictum about making each day matter. 

“He who is not courageous enough to take risks will accomplish nothing in life.” 

The final panel of the day surfaced the boldest ideas—though none yet sufficiently developed, let alone agreed upon. Still, the willingness to imagine some new affordability-promoting ideas was notable. 

Manny Lopes, CEO of Fallon Health, reminded the audience of the long-running success of the state’s program for frail, community-based elders who are dually eligible for Medicare and Medicaid. For roughly 25 years, this model—built on comprehensive care, integration of medical and social services, and a predictable per-member fee—has succeeded in improving health outcomes while reducing nursing home use. Lopes argued that a broader move toward such a system of total capitation could be an innovative path toward restraining spending growth and improving care coordination statewide. 

Doug Howgate of the Massachusetts Taxpayers Foundation floated a more budget-focused concept: creating a hard spending cap for Medicaid and then redesigning payment arrangements beneath that cap to cover as many people as possible. 

Kevin Tabb, CEO of Beth Israel Lahey Health, spoke about the need to “rationalize” care across the state—implying that Massachusetts may need to close low volume health facilities,  and less duplication of certain services.   He implied that there is no ‘free lunch’: if the state wants to reduce overall health care spending it will have consequences for the care delivery system and patient access. 

Blue Cross CEO Sarah Iselin pushed for making the state’s total per capita cost growth benchmark a firm, enforceable number for the total growth of health care spending—rather than only a guiding target.  Right now there is really only a weak performance improvement process (PIP)  that can be applied to a provider whose measured revenue growth per person is above the benchmark—currently at 3.6 percent.

In recent years, there has been little fear of any meaningful consequence for exceeding the benchmark growth rate—something that Iselin wants to change. She called for a benchmark accountability process with “real teeth and consequences” — presumably one that could even demand that monies be clawed back from market participants whose per capita revenue growth is above the benchmark. She even raised the possibility of exploring global hospital budgets—a payment model used in Maryland—if Massachusetts wants to genuinely restrain hospital spending growth. 

“A man who views the world at 50 the same as he did at 20 has wasted 30 years of his life.” 

As the day closed, members of the commission each offered brief reflections. What united them was a recognition that the system cannot continue functioning under the assumptions of 2012, when the last major health care cost law was enacted. There was a shared sense of urgency that Massachusetts needs a more comprehensive, coherent approach to achieving better health care affordability—one capable of maintaining access while reining in costs. 

Ali could afford to wait out his opponents, leaning against the ropes, conserving energy, and striking when the moment was right. For Massachusetts health care, time is not our ally.

The problems are accelerating faster than our solutions. The Legislature needs to recognize the urgency of the moment and that now is the time to come off the ropes and engage with purpose to stop the unchecked affordability challenges facing us all.  

Paul Hattis is a senior fellow at the Lown Institute.