When 2 in 5 people report delaying health care because of costs, something is wrong: The Boston Globe

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

That makes it crucial that the Massachusetts Health Policy Commission, along with the Legislature, establish an affordability benchmark, a new measure that would highlight how much consumers pay for health care, which could be used to make the health care system responsible for maintaining patient costs. downward.

The state has long struggled to contain its high health care costs, which are passed on to consumers through health insurance premiums and co-payments. According to the Center for Health Information and Analysis’ 2024 annual report, 41 percent of Massachusetts residents surveyed in a 2021 survey had trouble affording health care in the previous 12 months, including more than 50 percent percent of black and Hispanic respondents. Nearly one-third of residents said they did not need health care because of cost. A survey conducted in February and March 2024 for Blue Cross Blue Shield of Massachusetts found that 40 percent of respondents reported delaying care because of cost.

Struggles to pay for care are not surprising given the high cost of insurance. The average commercial health plan cost $595 per member per month in 2022, or $7,140 annually, a 5.8 percent increase from the previous year, according to the CHIA report. The average person with commercial insurance paid another $730 a year in cost-sharing. Because the plans are so expensive, more small companies are offering health plans with high deductibles, and 1.7 million Massachusetts residents were enrolled in health plans with deductibles of at least $1,400. Having a high deductible can deter 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 grew faster than wages or inflation. And these figures do not include the cost of care obtained outside the insurance system, for example, many mental health doctors require out-of-pocket payment.

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

This benchmark is important and should be expanded. For example, this editorial board has supported requiring pharmaceutical companies, pharmaceutical benefit managers, and drug wholesalers to testify about cost drivers related to prescription drugs. The provider review process should be expanded to cover all hospitals and specialty care providers, rather than just those with affiliated primary care physicians.

But a separate affordability benchmark is also necessary because reducing healthcare costs does not always mean limiting consumer costs, due to the complexity of healthcare systems. For example, if a drug manufacturer lowers the price of a drug through a rebate wrapped by a pharmacy benefit manager, the patient still pays the same amount.

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

That’s why a new measure that would monitor spending for patients with commercial insurance purchased through an employer or state exchange would be a valuable tool to better understand consumer costs and hold the health care system accountable. to contain them Ideally, this metric could be analyzed in ways that help policymakers understand whether certain populations have a greater cost burden, such as people with disabilities or chronic illnesses, or people of different races, ethnicities, ages, or income levels .

To be effective, the benchmark of affordability must be combined with accountability. The challenge will be to develop a fair way of holding the entire system accountable.

The easiest measure of affordability relates to how much consumers pay for insurance. But insurer benefits 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 benchmark, but is considering different accountability methods, including affordability as another factor in the current system of health cost reviews. and performance improvement plans; that the Insurance Division consider affordability when approving insurance rates; and develop a new system. While the commission can develop the affordability metric on its own, any accountability measure needs legislative approval. Lawmakers should make sure there’s a system with teeth to lower costs for consumers, and that it’s 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 addressed 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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