The state can better monitor the affordability of health care
The state can better monitor the affordability of health care

Despite Massachusetts’ reputation as a medical mecca, health care here is becoming increasingly unaffordable. And while the state has taken important steps to limit increases in the overall cost of care, those savings have not always been passed on to the consumer.

That makes it critical for the Massachusetts Health Policy Commission, along with the Legislature, to establish an affordability metric, a new measure that will highlight how much consumers pay for health care that can be used to hold the health care system accountable for the maintenance of the patients the costs are reduced.

The state has long struggled to contain its high health care costs, which are passed on to consumers through health insurance premiums and co-pays. According to the Center for Health Information and Analysis’ 2024 Annual Report, 41 percent of Massachusetts residents surveyed in a 2021 survey had problems affording health care in the previous 12 months, including more than 50 percent of blacks and Spanish-speaking respondents. Nearly one-third of residents report going without the need for health care because of the cost. A survey conducted in February and March 2024 for Blue Cross Blue Shield of Massachusetts found that 40 percent of respondents reported delays in care due to costs.

Difficulties paying for care are not surprising given the high cost of insurance. The average commercial health plan costs $595 per member per month in 2022, or $7,140 per year, a 5.8 percent increase from the previous year, according to the CHIA report. The average person with commercial insurance pays an additional $730 per year in cost sharing. Because the plans are so expensive, more small businesses are offering high-deductible health plans, and 1.7 million Massachusetts residents have been enrolled in health plans with deductibles of at least $1,400. Having a high deductible can discourage people from seeking care because they know they will have to pay out of pocket until the deductible is met.

Between 2020 and 2022, both premiums and cost-sharing are growing faster than wages or inflation. And those numbers don’t include the cost of care received outside the insurance system — for example, many mental health clinicians require out-of-pocket payment.

Massachusetts was the first state to establish a measure of health care spending growth. The Health Policy Commission, working with the Legislature, sets a target for health care spending growth each year. Providers and insurers must publicly testify at an annual hearing about how they keep costs in line. The Commission has the right to require any provider that does not adhere to the benchmark to adopt a performance improvement plan. (Only one plan was ever negotiated, with General Brigham.)

This indicator is important and should be expanded. For example, this editorial board supported requiring pharmaceutical companies, pharmacy benefit managers, and drug wholesalers to testify about the drivers of prescription drug costs. The provider review process should be expanded to include all hospitals and specialty care providers, not just those with primary care physician affiliations.

But a separate indicator of affordability is also needed, because containing health care costs does not always mean limiting consumer costs due to the complexity of the health care system. For example, if a drug manufacturer lowers the price of a drug through a rebate collected by a pharmacy manager, the patient still pays the same amount.

“Sometimes you can achieve savings at the system level, and that doesn’t always translate into the direct experience consumers have,” said Alex Scheff, senior director of policy and government relations for Health Care for All, a health care consumer advocacy group.

That’s why a new measure that would monitor the costs of patients with commercial insurance — insurance purchased by an employer or state exchange — would be a valuable tool for better understanding consumer spending and holding the health system accountable for containing it. Ideally, this metric could be analyzed in a way that helps policymakers understand whether certain populations have higher costs, such as people with disabilities or chronic illnesses, or people of different races, ethnicities, ages, or income levels.

To be effective, an accessibility metric must be coupled with accountability. The challenge will be to develop a fair way to hold the entire system accountable.

The easiest measure of affordability has to do with how much consumers pay for insurance. But insurers’ profits are already regulated, and the amount insurers charge reflects the prices doctors and drugmakers charge.

David Seltz, executive director of the Health Policy Commission, said the commission is still in the early stages of developing an affordability metric, but is considering different methods of accountability, such as including affordability as another factor in the current cost review system for health and performance improvement plans; have the Department of Insurance consider affordability when approving insurance rates; and developing a new system. While the commission can develop the accessibility metric itself, any accountability measure needs legislative approval. Lawmakers must ensure that there is a cogwheel system in place to keep consumer costs low, and that this is done in a way that includes providers, insurers and the pharmaceutical industry.

While no state has done exactly what Massachusetts is considering, other states have tackled health care affordability as part of broader efforts to contain costs, including Rhode Island, Connecticut, Vermont and California.

The best way to keep people healthy is to make sure everyone can get the care they need, when they need it, without worrying about whether they can afford it.

Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.

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