The Massachusetts Legislature has tackled the bankruptcy of Steward Health Care by passing a fairly comprehensive package of regulations that may help avoid another meltdown at a major medical system.

But there’s more to be done. Our health care system is a mess. We have allowed the marketplace to determine how health care is delivered, but the marketplace is about money, not health.

Our dollars are overwhelmingly spent on facilities, procedures, high-tech radiology, and miracle pharmaceutical cures, not on preventing the lifestyle choices that make them necessary. Massachusetts needs a comprehensive plan that will change how our health care dollars are spent while producing a healthier population.

Let’s start with primary care. In countries that have better health outcomes than the US, access to primary care physicians (PCP) and investment in prevention strategies are core elements of their systems. In the US, primary care has been on life support for decades, despite acknowledgment that PCPs are essential to producing an excellent and efficient system that results in a healthy population. New physicians overwhelmingly choose specialty fields, with the number choosing primary care recently dropping below 30 percent.

In Massachusetts, primary care is only 8 percent of health care spending, an indicator that primary care provider time with patients, essential to help guide patients toward healthy behaviors, is not perceived as important. The Commonwealth needs to promote primary care by ensuring that PCPs are paid competitively to specialists, making all primary care visits free of co-payments and deductibles, ensuring that prevention is a major part of health care visits, and forcing insurance to pay for fitness and nutrition programs.

While primary care withers, the costliest part of the health care system continues to expand exponentially. Running a marketplace-based system has produced intense competition between the remaining teaching hospitals, with the resultant building frenzy creating new hospitals and wings costing billions of dollars. For example, Mass General Hospital, part of Mass General Brigham, is building a $1.8 billion wing, while Dana Farber Cancer Institute, soon to join Beth Israel Lahey, is planning a new $1.7 billion hospital.

This bricks-and-mortar war has also resulted in the building of new specialty centers in wealthy suburbs where those with private insurance reside. A recent study by the Rand Corporation indicated that private health insurance pays 254 percent more than Medicare for services, which would explain the teaching hospital systems building hospital feeders in places where the well-insured live while not growing in areas with higher numbers of patients with Medicaid and Medicare. Meanwhile, community hospitals, largely in working class communities like Dorchester, continue their decline.

Despite these new and luxurious health care centers, 40 percent of the residents of our Commonwealth delay medical care because of its cost, which is among the highest in the world and outpacing inflation nearly every year. The class and racial gap in health care and structural racism within the system continue unabated. A study by Blue Cross Blue Shield last year indicated that “health disparities experienced by communities of color cost Massachusetts $5.9 billion a year,” mainly because of avoidable healthcare spending from waiting too long for care and lost labor productivity.

While Massachusetts leads the US in percentage of population covered by health insurance, it doesn’t mean that everyone has good health insurance or is able to afford care. The Massachusetts Connector (the agency created by Romneycare that provides access to private insurance for people who cannot get health insurance from an employer) has Deductible and Out of Pocket Maximums (OOPM), i.e., the most you can spend out of pocket, at $9,450 for an individual and $18,900 for a family for 2024. This is for those who have Connector insurance.
No wonder medical care continues to be the number one cause of bankruptcy in the US.

A few years ago, when I was CEO of the South End Health Center, 97 staff members were covered by health center-provided insurance. In the previous year, there were three insurance-covered people (one staff member and two spouses of staff members) who had serious illnesses that required hospitalization. Our insurance company increased our premiums by 28 percent because insurance companies today calculate rates by the organization’s annual health care cost (called “experience-rated”) rather than sharing the cost among a large risk pool, called community rated, which would prevent a few cases from causing a dramatic increase in premiums.

We tried to get other insurance companies to bid, but none would, because of the size of our risk pool. The result was a decision by the health center to increase our deductible to $3,000 and limit other care in an effort to reduce the increased premium.

In the US, 98 percent of businesses have fewer than 100 employees. Last year, a Massachusetts Health Policy Commission report indicated that employee premiums have increased by 295 percent since 2000, three times faster than household income and four times faster than inflation. Guiding insurance companies toward allowing larger risk pools made up of thousands of covered lives should be part of insurance reform, though ultimately a single payer system is the only real solution to the cost problem.

There are other issues that require our attention, including whether emerging “artificial intelligence” will be used to diagnose disease and deny care; the shortage of workers, especially nurses, that is getting worse as boomers retire; and the lack of regional ER coordination that has resulted in huge waits for care, and leaving some behavioral health patients to stay in emergency rooms, sometimes for weeks, because of problems with placing the patients in psychiatric hospitals.

I do not want to disparage the many parts of the system that work well, and the innovations that are helping to solve some of the issues I have identified. However, there are huge issues that need to be comprehensively tackled, and it’s time for the Commonwealth to create a commission that can do that. It needs to be made up of people without the vested interests that seek to perpetuate the existing system.

We need a fresh view of how to solve the problems in how medical care is delivered. In 1991, Professor Nancy Kane of the Harvard School of Public Health provided a thorough analysis of the Massachusetts hospital system of that era, which prompted discussions how we use health care dollars. In a Boston Globe article by Richard Knox (2/3/1991), Kane said something that is still relevant today: “There’s a tradeoff between how much we want to pay, how much high-tech plant and equipment we want, and whether we want these institutions to tackle social problems like infant mortality and drug abuse.”

We need another independent and comprehensive review of the Massachusetts health care system, and a plan to create a system that produces more health and less cost. It’s done elsewhere; it can be done here.

Bill Walczak is a Reporter columnist and a Dorchester reference who was co-founder and CEO of the Codman Square Health Center. Among his many roles, he worked as president of Carney Hospital, owned by Steward Health Care System, in 2011-2012.