A physician’s perspective on the crisis in Massachusetts health care

The Massachusetts paradox: best-in-class care, bottlenecked access

Massachusetts routinely ranks near the top on many health indicators. We have high insurance coverage, dense medical expertise, and a culture that
(mostly) believes in science, vaccines, and washing your hands like you’re about to scrub into surgery.

So why does it feel like the system is in crisis?

Because “quality” and “capacity” are not the same thing. You can have extraordinary clinicians and still have a system that can’t move patients through
efficiently, can’t keep up with demand, and can’t afford itself. Think of it like owning a Michelin-star kitchen with one overworked dishwasher: the food can
be incredible, but the line still wraps around the block.

What the crisis looks like from the exam room

1) The waiting room keeps expandingwithout adding chairs

Demand has climbed. The population is aging. Chronic disease is more common. Behavioral health needs are higher than they were a decade ago. And more
people, understandably, want timely care. In practice, that means appointment calendars packed to the margins and patients who “waited it out” until their
symptoms became un-ignorable.

When you can’t get a primary care appointment, you don’t stop getting sickyou just change where you show up. The emergency department becomes the
default, even when it’s the least efficient place to manage a long list of non-emergency problems.

2) Workforce shortages are betterand still not good enough

Massachusetts hospitals have made real progress rebuilding staffing after the pandemic shock. But “better” can still mean “painful.” Vacancies ripple
outward: fewer staffed beds, longer ED waits, delayed procedures, and exhausted teams who spend half their day compensating for gaps.

Clinically, you notice it as the little frictions that add up: the nurse covering more patients than is safe, the case manager juggling discharges across
three floors, the respiratory therapist bouncing between units like a pinball, the social worker who can’t possibly return every call before lunch.

And yes, physicians are part of this too. Primary care and behavioral health are especially tight. The irony is cruel: the parts of the system that prevent
crises are the parts the system under-supplies.

3) The “throughput” problem: we’re not stuck because people won’t leavewe’re stuck because there’s nowhere to go

A hospital is not meant to be a long-term holding area. But when post-acute capacity is limitedskilled nursing, rehab, home servicespatients who are
medically ready can’t leave. When they can’t leave, beds can’t open. When beds can’t open, admitted patients stay in the ED. When admitted patients stay
in the ED, the ED can’t see the next wave. This is how a system backs up without anyone doing something “wrong.”

From a physician perspective, this is maddening because it turns hospital medicine into hotel management. Our teams become experts in the least
satisfying clinical question of all: “Where can this patient safely go?” That’s not a medical failure. It’s a system design failure.

4) Behavioral health boarding: the crisis inside the crisis

Behavioral health boarding happens when patients waitsometimes for a long timein emergency departments or medical floors until an appropriate
behavioral health bed is available. It is unsafe, demoralizing, and wildly inefficient.

EDs are not built for extended psychiatric care. Medical floors aren’t either. Yet clinicians across the Commonwealth routinely care for people in crisis
in spaces never designed for that purpose. The result is a dual harm: patients don’t get the therapeutic environment they need, and hospitals lose capacity
for everyone else.

5) Affordability whiplash: everything costs more, and everyone feels it

Massachusetts health care is expensive in ways that hit both patients and employers. Premiums rise. Deductibles rise. Copays rise. Meanwhile, wages
don’t always keep pace. For patients, that means delaying care, skipping medications, or trying to “tough it out” until the problem becomes urgent. For
clinicians, it means more complicated conversations about cost, coverage, and what’s realistically doable.

And nothing makes a patient feel like a valued human being quite like spending 20 minutes on the phone arguing with a robot about whether they’re
allowed to have the medication their doctor prescribed. (If you’re wondering why physicians get cranky about prior authorization, that’s why.)

Follow the moneycarefully, because it’s complicated

Hospital finances are a confusing mix of operating margins, non-operating gains, payer mix, labor costs, pharmacy costs, and the occasional “why is this
stapler $19?” moment. Some years look better on paper while the day-to-day reality still feels unstable. You can see profitability rebound in aggregate
while individual hospitalsespecially those serving high-need communitiesremain vulnerable.

Temporary labor spending is one of the clearest examples of the pandemic aftershock. When you can’t hire enough permanent staff, you pay premium rates
for travelers. It keeps doors open, but it’s expensive and it erodes continuity. Clinically, it’s the difference between a team that’s practiced together for
years and a rotating cast doing their best in a system they’re still learning.

The Steward saga: why ownership structure matters to patient care

If you want a real-world case study in how finance can destabilize care delivery, Massachusetts has lived it. Steward Health Care’s collapse and hospital
transitions weren’t just business headlinesthey were community access emergencies. When a hospital closes or teeters, it doesn’t only affect that
building. It affects ambulance routing, neighboring ED crowding, specialist availability, staffing stability, and the emotional trust patients place in “the
system.”

As clinicians, we felt it as uncertainty: Would a service line disappear? Would a referral network fracture? Would patients delay care because they didn’t
know if the doors would still be open next month? Health care is not a normal market good. You don’t price-shop during a stroke.

That’s why oversight, transparency, and financial accountability matter. Not because doctors want to read balance sheets for fun (we do not), but because
fragile finances become fragile access, and fragile access becomes worse outcomes.

Primary care: the foundation we keep treating like an optional add-on

Primary care is where prevention happens, where chronic illness is managed, where mental health is often first detected, and where patients build the
relationships that keep them out of the hospital. Yet primary care practices are frequently squeezed by volume-based payment, administrative burden, and
a workforce pipeline that doesn’t produce enough clinicians who want (or can afford) to do this work long-term.

In Massachusetts, the signals are loud: many residents report difficulty obtaining necessary care, and the share of spending devoted to primary care
remains a relatively small slice of total spending for major payers. If the system is a house, primary care is the foundation; right now, we’re decorating the
roof while the foundation begs for reinforcement.

The fix isn’t a single program. It’s a rebalancing: pay for access and continuity, reduce administrative friction, support team-based care, and make it
realistic for clinicians to choose primary care without sacrificing financial stability or sanity.

What would actually help: a physician’s short list (with minimal fantasy)

1) Make it easier to do the right thing

• Simplify prior authorization for high-value, guideline-supported care.
• Standardize payer rules where possible so clinics don’t need a different playbook for each insurer.
• Invest in care coordination so clinicians aren’t doing social work with a stethoscope.

2) Treat behavioral health capacity like critical infrastructure

If 400–600 people are waiting in emergency departments for behavioral health care on a regular basis, that is not a niche problem. That is a statewide
capacity failure. We need more beds, yesbut also more community-based services, more step-down options, more crisis stabilization, and more workforce
support so the pipeline can staff the services we build.

3) Fix post-acute flow (or the hospital will remain the world’s most expensive waiting room)

This means strengthening skilled nursing and rehab capacity, expanding home health where appropriate, supporting caregivers, and making it financially
viable to provide high-quality post-acute services. A hospital bed should be a place for acute carenot the end of the line because the rest of the line is
missing.

4) Buildand keepthe workforce

Recruitment matters. So does retention. The frontline reality is that people stay when they have safe staffing, predictable schedules, supportive leaders,
professional growth, and a workplace where violence is addressed seriously instead of treated as “part of the job.” Training pipelines help, but so does
making the job survivable once people arrive.

5) Keep affordability front and center

When cost-sharing rises faster than wages, patients delay care and outcomes worsen. Affordability is not a “consumer experience” issueit’s a clinical
issue. If the goal is better population health, pricing people out of preventive care is a self-defeating strategy.

So…is there hope?

Yesif we stop pretending there’s one lever.

The Massachusetts health care crisis isn’t a single villain twirling a mustache in a boardroom. It’s a pileup: high costs, staffing constraints, behavioral
health demand, post-acute bottlenecks, and ownership instability colliding on the same narrow roadway. You can’t fix it with a press release or a
committee alone. You fix it by widening the road, reducing the number of crashes, and staffing enough people to keep traffic moving.

Clinicians will keep showing up. Nurses will keep doing heroic work. Hospitals will keep adapting. But without structural changes, we’ll keep burning
through goodwillthe one resource no budget can replace.

Experience notes from the trenches (about )

Let me end with a few moments that capture this crisis better than any chart.

Moment #1: The “medical clearance” mirage. A patient arrives in the ED in psychiatric crisis. We do what we’re supposed to do: assess
safety, rule out acute medical emergencies, start treatment. Within hours, we’ve done the medical work. And then…nothing. The patient waits. And waits.
The ED staff tries to create a calm environment in a place designed for alarms, bright lights, and constant motion. We build “privacy” with curtains and
hope. Meanwhile, the waiting room fills with people who can’t breathe, people with chest pain, parents with sick kids. The team is caring for everyone at
once, which is another way of saying no one is getting what they truly need. It’s like trying to conduct therapy in the middle of a fire drill.

Moment #2: The discharge that isn’t a discharge. On rounds, we celebrate a win: a patient’s pneumonia is improved, oxygen needs are
down, labs look better, and they’re ready for rehab. Then the real work begins. Case management calls facilities. Facilities say they’re full. Or they don’t
have staff. Or the payer process is slow. Or the patient needs a specialty bed that exists somewhere in theory, like Bigfoot. The patient stays two more
days. Then five. Then nine. By day nine, the hospital is essentially providing expensive room-and-board to someone who would do better in a quieter
setting. Everyone knows it. No one is satisfied. And each “extra” day quietly blocks a bed for the next acutely ill patient.

Moment #3: The primary care squeeze. In clinic, I see the downstream effects of delays: a blood pressure that could’ve been controlled
months ago is now an urgent visit because the patient couldn’t get in sooner; a rash becomes an infection; anxiety becomes panic. Patients apologize for
needing help. I tell them the truth: you never have to apologize for being a human with a body. But the system has trained them to feel like a burden.
That’s the sneakiest kind of crisiswhen people start rationing care out of shame.

Moment #4: The prior authorization comedy that isn’t funny. A patient needs a medication that prevents hospitalization. Everyone agrees
it’s the right choice. Then the paperwork begins. The patient thinks I’m “ordering” a drug like I’m clicking a button. In reality, it’s calls, forms, faxes
(yes, still), and long waits for decisions that can change with the plan year. I’ve had patients who could navigate Boston traffic in the rain with one eye
closed but could not navigate their own pharmacy benefits. I don’t blame them. I blame a system that treats access as a puzzle.

Moment #5: The team that keeps showing up anyway. Despite everything, I watch nurses teach new nurses, residents stay late to comfort
families, and support staff do the invisible work that keeps a hospital functioning. The crisis is realbut so is the commitment. If Massachusetts wants to
protect its reputation for world-class care, the most practical move is also the most human: invest in the people and the pathways that make care
accessible, timely, and safe.