Dr. Katherine Gergen Barnett is associate professor of family medicine at Boston University Chobanian & Avedisian School of Medicine, vice chair of primary care innovation and transformation at Boston Medical Center, and communications fellow at Primary Care Collaborative.
The Massachusetts Senate recently passed a long-overdue change to the foundation of health care in the state by boosting support for primary care. But the measure, which aims to rearrange funding without increasing costs, will only be effective if lawmakers support the other pillar of the health care system: safety net hospitals, where all changes to health laws are first, and most acutely, felt.
Prioritizing primary care is the most prudent thing any health system can do. Having a primary care provider is associated with 54 percent lower health care costs for adults with chronic disease, 20 percent fewer hospitalizations, and 11 percent fewer emergency department visits. And yet in Boston, new patients wait an average of 40 days to see a primary care doctor (twice the average than in comparable cities), the percentage of medical students entering primary care continues to decline, and the percentage of primary care physicians exiting primary care is at an all-time high. This leaves patients resorting to the most expensive care outcomes: emergency care, late diagnoses, and preventable suffering.
The Massachusetts bill tackling this issue passed the Senate last month and is before the House. It takes an important step toward addressing this crisis by reforming how primary care is financed, regulated, and measured. It establishes statewide primary care spending targets, increasing the share of total health care expenditures devoted to primary care from the current rate of 6.7 percent to 15 percent by 2030 — without raising overall health care costs or increasing premiums.
Additionally, by shifting reimbursement toward a per-member, per-month model, it rewards doctors who maintain their patient relationships over simple patient volume; a doctor retaining 10 regular patients earns more than one churning through 10 new intakes but keeping none. The bill also unlocks federal Medicaid matching funds to support medical residencies, ensuring that Massachusetts no longer leaves that money on the table. Finally, it aims to increase the rate that commercial plans pay to Federally Qualified Health Centers. Currently these community health centers receive only about 65 percent of what commercial plans pay other office-based practices for a comparable physician visit.
These regulations would be measured by the Center for Health Information and Analysis and regulated by the Massachusetts Health Policy Commission.
The bill is now in the House, where members not only have the opportunity to build upon the Senate proposal but also can address the outsized impact that this legislation will have on safety net systems. While the 15 percent spend mandated in the Senate’s bill will be an important change for all providers and payers, reaching these benchmarks will be particularly challenging for safety net providers — facilities that treat the highest number of uninsured, elderly, and low-income patients — which are already struggling financially and will face additional federal cuts in the near future.
Federal spending cuts loom as a result of the One Big Beautiful Bill Act signed into law last year. The Congressional Budget Office estimates there will be $911 billion in cuts to national Medicaid spending over the next decade. Massachusetts alone stands to lose up to $3.5 billion in annual federal health care funding in the next three years. The Blue Cross Blue Shield of Massachusetts Foundation projects that 141,000 to 203,000 state residents will lose MassHealth coverage through specific provisions of the law and, with it, their primary care. Beginning in 2027, some members will face work requirements and eligibility checks every six months that will put a tremendous burden on patients and clinicians alike.
I am honored to have worked on the front lines of primary care in the largest safety net hospital in New England for the past 21 years and know all too well that hospitals like mine don’t simply serve low-income and traditionally marginalized communities. We are the institutions that absorb every gap the rest of the system creates. When insurers narrow their networks, patients come to us. When federal policy strips coverage, patients come to us. When people wait 40 days for a primary care appointment and give up, they come to our emergency department. We are not just stakeholders in this legislation — we are the floor beneath it.
The state has the opportunity to build a healthier Massachusetts by improving primary care for our residents. The Legislature should pass this bill, but it must also ensure that the health safety net holding up the most marginalized members of our community does not suffer in the process. It should fund the Massachusetts Health Safety Net adequately as the uninsured population grows. And it should use as much leverage as possible — including the bully pulpit of a state that pioneered universal coverage — to fight the federal cuts that are undermining primary care legislation before it is even signed.