THE PROSPECTS FOR meaningful reforms addressing health care affordability in the state feel bit a bit like the chances the Red Sox have in the postseason: The local nine are a near-lock to make the playoffs, but whether they can advance even past the first round is harder to count on.

There have been some promising initial moves on health care policy, but whether state leaders can translate that momentum into tangible wins when it comes to greater health care affordability now hangs in the balance. Key actions by the Legislature and several state agencies will determine whether we look back on this year as a success or failure for state health policy actions—especially in starting to tackle commercial health care affordability, arguably our biggest challenge right now.

Like the Red Sox season, the health care picture in the state this year has been marked by big ups and downs.

The downs have been significant: double-digit premium increases for families and businesses; some legal immigrants excluded from subsidized Connector coverage; and middle-class residents priced out of Connector plans altogether after Congress failed to renew the expanded COVID-era federal subsidies.

Add to that the loss of bedside caregivers as TPS protections lapsed for Haitian and other immigrant groups. And the CVS-Mass General Brigham MinuteClinic deal, moving forward without pricing or revenue-flow constraints, will surely add to the bottom lines of those two corporate entities, while it is much less clear that it will do much to address the state’s primary care shortage.

The ups include the limited rollback by the Department of Insurance of prior-authorization burdens facing patients. Beyond that, the positive developments remain works in progress. On Beacon Hill, the Senate and House have each passed a primary care bill responding to the recommendation of a state Primary Care Task Force. And members of the governor’s Health Care Affordability Working Group held private discussions that produced arguably quite tame initial recommendations in early August. She has promised more by later in the year.

Whether either the primary care or health care affordability efforts land on the positive side of the ledger depends entirely on what happens between now and year’s end.

The primary care bills

The primary care bills passed by each branch of the Legislature now sits with a joint House and Senate conference committee, which must reconcile the two versions. Both have real merit. They each increase the flow of dollars to primary care clinicians (on slightly different required schedules), mandate higher payments to community health centers, and seek to expand the primary care workforce pipeline. Importantly, they also attempt to move primary care payment away from fee-for-service. The Senate does so through a Health Policy Commission-monitored capitation model, while the House looks to the Department of Insurance to oversee a value-based payment approach.

Unfortunately, both bills share a major weakness: Neither requires primary care dollars to actually be redistributed away from hospitals and specialists while stopping overall health care spending from growing beyond the annual growth benchmark set by the state.

The Senate’s approach is to establish a distinct primary care spending target. And if providers or insurers do not hit the target, they could get placed on a performance improvement plan to try to get them there. But the language of the Senate bill calls for escalating civil penalties only if the improvement plan is totally ignored or given only minimal effort; the penalties are not tied to simply failing to meet the spending target.

The House version is even weaker—as it left financial penalties out of the scheme entirely—even for failing to make a good faith effort on a performance improvement plan.

I would much rather see a firmer requirement that is backed by actual penalties for failing to redistribute spending towards primary care—especially in a year when the overall state spending growth target is breached. Maybe the legislative conference committee can find a solution that will get us there. Otherwise, the primary care spending target risks becoming another well-intentioned benchmark that does little to change where health care dollars actually go.

The Health Care Affordability Working Group

The governor’s Health Care Affordability Working Group recommendations look more like a placeholder list than a serious affordability strategy. Much of the early-August wish list amounts to telling various groups to keep talking, with the hope that they will eventually land on strategies for innovative care delivery, moving stuck patients out of inpatient beds, workforce investments, lowering drug costs, and using AI to cut costs. In short: it looked like a working group recommending more working groups.

Most notably absent is any real acknowledgment of what is actually driving Massachusetts health care spending: high provider prices and the market power of a handful of large, prestigious systems.

I had hoped for a recommendation along the lines of a fixed total annual revenue budget covering all Massachusetts commercial and Medicaid hospital patients. As a new concept for our state, it might make most sense to start with the most financially challenged hospitals. That does not appear to be in the cards yet, but the idea may not be too far down the road. Pairing this hospital payment model with a common fund for primary care could help our system deliver better care while capturing real administrative savings—and demonstrate to Washington that both concepts could work for Medicare as well.

But two recommendations from the working group give me some hope.

The first directs the Division of Insurance to set default out-of-network payment rates by regulation, covering areas the federal surprise-billing law enacted in 2020 left untouched. In Massachusetts, surprise bills have traditionally come mostly from physicians, but the biggest offender today is ground ambulance services, whose out-of-network pricing badly needs reining in. And though Massachusetts hospitals are almost always in-network, some believe the DOI’s effort here could also help providers and insurers negotiate in an environment that may be more likely to achieve fairer and more reasonable hospital prices.

The second promising recommendation asks the Group Insurance Commission, which oversees coverage for public employees, albeit without much detail, to develop a system of “fair hospital prices” for its enormous book of commercial business—covering state employees and a substantial number of municipal employees.

The GIC has options: price caps tied to a multiple of Medicare rates; reference pricing tied to the market median, putting pressure on high-priced providers to lower their prices or lose market share; or refusing to pay for low-value care while holding beneficiaries harmless.

Success in implementing one or more of these pricing constraints for GIC beneficiaries could have effects well beyond those public employees and their families. It could demonstrate that insurers and self-insured employers have practical tools for reining in hospital prices and, in turn, putting pressure on the broader commercial market to follow.

But there is an important caveat: GIC savings cannot come at the expense of everyone else. If hospitals respond by simply shifting higher prices onto the rest of the commercial market, the policy will have moved costs around rather than controlled them. If that becomes the game, there may be little choice but to move toward a fixed annual revenue model for hospitals across the entire market.

If the Legislature can get a primary care bill across the finish line that includes an effective total-cost-of-care limit tied to meaningful redistribution toward primary care—and if the Division of Insurance and Group Insurance Commission can actually follow through on the most promising affordability recommendations that they have been charged to carry out—there could be real progress on health care affordability before year’s end.

That would feel a lot like not just making playoffs, but getting at least past the first round.

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