‘The gaps have become too big for too many’

by Chris Lisinski, CommonWealth Beacon
September 23, 2025

WHEN A GROUP OF health care practitioners, policymakers, and industry leaders gathered last week to continue their examination of Massachusetts’s faltering primary care system, the discussion turned more than once to Albert Einstein.

Attendees were not hopeful that general relativity or a mathematical proof might provide the key to reinvigorating a shrinking workforce or to cutting the months-long wait patients face for new appointments. Instead, they referenced a quote often attributed to Einstein: “Insanity is doing the same thing over and over again and expecting different results.”

Stephen Martin, a physician and UMass Chan Medical School professor, invoked the famous – and likely apocryphal – quote to urge his counterparts to take big swings in their work.

“The arrangements we have going forward, if they are not different from what we have now, we should expect failure, just as Einstein said many, many years ago,” Martin said at a meeting of the state’s primary care task force earlier this month. “If there’s not a delta in what we eventually come to, we should be wary of any constructive results.”

Some policymakers and advocates have spent years trying, and failing, to convince legislative leaders the state should force new investments in primary care. Former Gov. Charlie Baker twice filed bills that would have required providers and insurers to boost their spending on primary and behavioral health care. Those provisions never earned a vote in the House or Senate, and Baker reflected shortly before he left office that his effort to overhaul the payment model “freaked everybody out.”

But as conditions on the ground worsen for patients and burnt-out providers, supporters say they sense growing momentum for a primary care spending goal that would steer more money toward the system’s front lines.

“I would be surprised if by the end of this legislative session, there was not major primary care legislation that included a primary care spending benchmark,” Wayne Altman, a physician and founder of the Massachusetts Primary Care Alliance for Patients, told CommonWealth Beacon.

Massachusetts already has a benchmark in place for total health care spending, designed to set a goal for keeping cost growth limited. It’s had limited success: Total health care expenditures per capita increased 8.6 percent in 2023, more than twice the 3.6 percent benchmark.

Some advocates and lawmakers have been clamoring to add a primary care-specific spending target to state law, a metric that would dictate how much more providers and insurers need to spend or what share of their health care dollars need to go toward primary care.

While many industry leaders and elected officials tout the value of primary care, only a small fraction of health care dollars actually flow its way. In 2023, the most recent year with state data available, MassHealth spent about $35 per member per month on primary care services, or 7.5 percent of its total health care expenses. The share of spending on primary care was even lower for commercial health plans (6.7 percent) and Medicare Advantage (4.2 percent).

Significantly more money goes to other areas of spending. In 2021, commercial health plans spent about $2,108 per person per year on hospital outpatient care, such as surgeries and drug infusions, according to Health Policy Commission data. They spent less than one-quarter as much – $500 per person per year – on primary care.

A hospital oversight law Gov. Maura Healey signed in January created the 25-member task force and assigned it with crafting recommendations on how the state should define and track primary care services, strengthen the workforce pipeline to bring new providers into the field, and set a specific spending target for primary care.

Asked if the governor would support codifying a primary care spending target, a Healey spokesperson on Monday did not answer directly and said only that the governor “will review the recommendations of the task force.”

The panel faces a mid-December deadline to report its findings on primary care spending targets. At a September 17 meeting, several members voiced support for the idea of requiring a certain share of health care expenses to go toward primary care.

HPC Executive Director David Seltz floated one possible approach to tee off debate: setting a target that 15 percent of total medical spending in Massachusetts would be allocated for primary care by 2034, phased in over an eight-year span with an increase of one percentage point per year.

Seltz said that would increase spending on primary care by a bit more than 10 percent each year.

The spending target would be only one reform among many others, and Seltz mentioned changes to payment and care delivery systems as important complements. But he called a specific threshold written into statute “a bold message as a state to say, ‘This is what we’re working towards, and we’re all working towards this together.’”

Both Altman and David Gilchrist, executive chair of primary care for Atrius Health and Reliant Medical Group, countered during the task force discussion that they feel an eight-year ramp is “way too long.” Instead, they suggested more than doubling the share of spending over a four-year period instead.

“The struggle with primary care is like a tug of war. The Massachusetts state Legislature just put 25 people on our side of the rope to try and help with this tug of war to fix primary care, except we keep losing. Even though there’s 25 more of us on this side of the rope, we’re going backwards,” Altman said. “We don’t have eight years. Our patients don’t have eight years to wait to fix this.”

But one key detail could fuel a fight ahead: Supporters want to increase the share of spending on primary care without accelerating overall health care spending growth, which is already careening past cost-control targets.

Growing one slice while keeping the pie about the same size would mean less money for other areas, like specialty care and pharmaceuticals. Those segments of the industry are not pushing back yet – at least not in public – and opposition could arise as the debate unfolds.

“We haven’t heard anyone really loudly opposing this idea yet, but I think as it builds more momentum, we’ll probably start to hear from more of those players,” said Suzanne Curry, director of policy initiatives at Health Care for All.

Lora Pellegrini, who leads the Massachusetts Association of Health Plans, said insurers would back a primary care spending benchmark if it did not result in overall expense growth.

“So long as we’re not adding new dollars to the system and we’re working within the benchmark of existing expenditures, the plans are very supportive of enhancing primary care practices and transforming them so that they can really invest in wellness models of care and keeping people out of the hospital and out of the emergency room,” she said.

Supporters say deploying a greater share of funds to primary care can pay economic dividends in the long term by catching problems early or preventing them altogether, thereby avoiding costlier emergency care.

While the task force’s recommendations continue to crystallize, there’s no shortage of urgency.

The HPC issued a stern warning about the outlook for primary care in January with a report – titled “A Dire Diagnosis” – that found an aging workforce, a sluggish pipeline of new physicians entering the field, and long wait times for appointments.

Valerie Fleishman, chief innovation officer for the Massachusetts Health and Hospital Association that represents hospitals and health systems, said the industry group is “especially alarmed by the workforce trends” in that report.

“Even while Massachusetts outpaces much of the nation in primary care spending and access, the gaps have become too big for too many,” Fleishman said, pointing to research from the Milbank Memorial Fund that identified significant primary care problems across the country.

“We look forward to seeing how the [task force’s] recommendations can help align our system’s primary care strategy, build up this essential profession, and address the financial limitations that providers are facing,” she added.

The growing shortage of primary care providers spells major headaches for patients.

One in four Massachusetts residents surveyed in 2023 reported they were unable to get an appointment with their doctor’s office or clinic as soon as they needed it, according to the HPC. Two in three sought care in the emergency department for a nonemergency condition because they could not get an appointment.

A CommonWealth Beacon poll published this month found 24% of Bay Staters waited between three weeks and two months to see their primary care provider. Another 20% waited longer than two months.

Patients in the Boston area face some of the longest waits in the country to book routine check-ups.

Researchers at AMN Healthcare, an industry staffing company, earlier this year contacted physician offices in 15 major metropolitan areas to schedule new patient appointments and recorded how long someone would need to wait.

A patient in the Boston area faced an average wait of 69 days when booking a physical with a new provider, by far the longest of all 15 cities surveyed and nearly three times the average from the full sample, which also included New York City, Seattle, and Philadelphia, according to a report published in June. (The average wait in Boston was even longer for some specialty care such as cardiology or obstetrics and gynecology, AMN found.)

“The primary care crisis is ever-deepening as we’ve been meeting,” Health and Human Services Secretary Kiame Mahaniah noted at the task force meeting.

Some entities are pursuing new approaches in the meantime. Mass General Brigham and CVS proposed an affiliation in which MGB patients could receive in-network primary care at MinuteClinics operated by the pharmacy giant across the state.

The HPC voted to subject that proposal – which drew skepticism from some physicians – to a more extensive cost and market impact review, which will analyze its expected impact on health care spending.

Early in the 2025-2026 legislative session, Healey and Senate President Karen Spilka both signaled interest in supercharging primary care, but both stopped short of supporting a specific primary care spending benchmark. Neither have put forth specific policy recommendations.

Healey used her State of the Commonwealth address in January to pledge to “shift health care resources to the front lines.”

“I want a whole army of primary care providers out there, so when you call for an appointment, you’ll get one,” she said. “You’ll get the affordable care you need, where and when you need it.”

In her own inaugural remarks two weeks before Healey’s, Spilka said she planned to examine “comprehensive health care reform, including taking a close look at primary care delivery.”

One top Spilka deputy, Sen. Cindy Friedman, is one of Beacon Hill’s biggest proponents of enshrining a primary care spending target. Friedman again filed legislation this term that would gradually impose a requirement for 12 percent of total medical spending to go toward primary care, among a suite of other reforms to payment models and behavioral health coverage.

In an interview, Friedman said she expects that some kind of primary care legislation is “in the mix” this term, especially as federal funding cuts squeeze the state’s broader health care system.

“Maybe people will be more attentive because we are going to be losing lots of federal dollars, and we’ve got to take some of the pressure off of our hospitals and our hospital systems,” Friedman, one of the Legislature’s representatives on the primary care task force, said. “People without insurance are going to show up in emergency rooms – which is incredibly expensive, right? – so if we can’t figure out a way to get up front of this problem, get at the front door, which is primary care, then we are going to just exacerbate a very, very bad situation.”

The outlook in the House is less clear. In January, after Healey’s annual speech, House Speaker Ron Mariano called primary care “an interesting challenge.”

“I’ve been doing health care since 2006. We’ve had a couple of initiatives to create additional primary care. We’ve put incentives to medical schools, tuition rate for primary care. It’s very difficult to get doctors to enter into a primary care practice,” he said at the time, according to State House News Service. “I’ll listen to what [Healey and Spilka] have to say, but I know there are certain barriers that are hard to get over if you want to create primary care.”

Past attempts to force an increase in primary care funding have gone nowhere in the Legislature.

Baker filed bills in 2019 and 2022 that sought to force providers and insurers to boost spending on primary care and behavioral health services.

His plans took a different approach than the legislation currently pending on Beacon Hill.: Instead of requiring a specific share of total health care spending to go toward primary care, Baker’s bills would have called on insurers to boost primary care spending 30 percent over three years without increasing the state’s overall benchmark for health care cost growth.

Neither proposal advanced beyond the Health Care Financing Committee, which Friedman has co-chaired since 2019.

Friedman said policymakers and stakeholders struggled with Baker’s bill to figure out how to track whether additional dollars would flow toward primary care. The task force’s work should help address those issues, she said.

“The other piece … that makes it really challenging is we don’t want to spend more money. We just want to spend money differently,” she added. “A hospital will say, ‘Hey, yeah, sure, let’s spend more money on primary care, but don’t take it away from filling beds, [or] don’t take it away from the specialists that we have.’”

Curry, of Health Care for All, recalled that Baker was one of the first to make a concrete push for increased primary care investment. At the time, she said, “there wasn’t really as much of a groundswell from other folks outside of government as there is now.”

Asked why the idea has been so hard to get over the finish line, Friedman said “the devil’s in the details.”

“In any change, somebody has less of something when somebody has more of something,” she said. “Different stakeholders see that, and they get anxious. In this environment, where health care is just being attacked so constantly by the federal government, people just are even more anxious. It’s human nature, when you get scared to pull back, to fight or flight, and entities do the same thing, when it really behooves us, what we really should be doing is sitting down together and figuring out how we can do the least harm while we’re taking care of such an important and critical issue for our residents.”

So what gives backers any confidence the latest advocacy push will be any different?

Part of it, Altman said, is the existence of the task force, which will put concrete ideas into writing in response to a legislative request. The other key factor is just how bad the situation has gotten since the first bill was filed years ago.

“The problem is worse, the crisis is deeper than it’s ever been,” he said. “Usually, when there are crises that affect poor people, they tend not to get too much traction. When crises affect people of all socioeconomic strata, they tend to get traction, and this primary care access crisis is affecting everybody.”

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‘The gaps have become too big for too many’

Chris Lisinski, CommonWealth Beacon
September 23, 2025