As Massachusetts marks twenty years since the passage of Chapter 58, the state is doing more than looking back. The next phase of reform is already underway—shaped not just by history, but in the rooms where policy decisions are being made now. Those conversations are bringing together leaders across the system. And for home care and hospice, representation is not assumed. It is earned.

When Chapter 58 was signed in 2006 at Boston’s Faneuil Hall, it was framed as a breakthrough—and it was. The law created a path to near-universal coverage through a combination of subsidies, an individual mandate, and the creation of the Massachusetts Health Connector. It brought together political leaders across parties and aligned stakeholders around a shared goal: coverage for nearly all residents.

That model did not stay in Massachusetts. It became a clear template for the Affordable Care Act, helping shape how coverage expansion would later unfold across the country. The law proved that broad coverage was not only politically possible, but operationally achievable.

The results are measurable. Massachusetts still leads the nation in coverage, with roughly 98 percent of residents insured. More than 400,000 people who had previously been uninsured gained coverage after reform took hold. The Commonwealth strengthened access, improved public health, and established itself as a national example of what health reform could accomplish.

That is the reality defining the next chapter of reform.

Affordability has emerged as the central pressure point. Coverage may be widespread, but costs continue to rise faster than wages. Families are feeling it in premiums and out-of-pocket expenses. Employers are feeling it in annual increases that are becoming harder to absorb. Public programs are feeling it in the growing challenge of long-term sustainability.

Providers are feeling it, too. Across the system, rising costs, workforce shortages, administrative complexity, and increasing patient acuity are reshaping what care delivery actually looks like. For home-based care providers, these pressures are immediate and operational. They affect staffing, scheduling, reimbursement, and the ability to meet demand in the lower-cost, patient-preferred setting of the home.

The debate, in other words, has changed. Chapter 58 solved for coverage. The next phase of reform is about whether that coverage is affordable to use, sustainable to support, and strong enough to deliver meaningful access in practice.

Sánchez recently reflected on how then-Speaker Sal DiMasi described the reform effort: everyone was on the same boat, moving forward together. The expectation was never stability—it was resilience. The system would be tested, adjusted, and rebuilt as conditions changed.

Two decades later, that moment has arrived. With affordability pressures mounting and federal policy shifts adding new uncertainty, Massachusetts is once again facing the need to adapt—not from scratch, but from a system that has already proven what is possible.

That challenge was never entirely unforeseen. Jeffrey Sánchez, who served in the Massachusetts House when reform passed, recently recalled then-Speaker Sal DiMasi’s nautical metaphor for the work ahead: everybody was on the boat together. The understanding, even then, was that the seas would be choppy—and that part of the storm was always going to be cost.

Two decades later, that metaphor still holds. With federal funding uncertainty, affordability pressures, and policy changes that threaten to erode coverage gains, the system is not simply being commemorated. It is being tested. The question is no longer whether Massachusetts can expand coverage. It is whether the state can adapt again—this time to preserve access, improve quality, and keep care financially within reach.

That is what makes the current policy conversations so important. They are not retrospective exercises. They are working discussions about what comes next—and who is in the room when those decisions are being shaped.

For home care and hospice, that matters. Care at home is no longer peripheral to the health care system. It is central to how the Commonwealth manages access, quality, patient preference, and cost. Any serious conversation about the future of Massachusetts health care must account for how care is delivered outside hospital walls and across the continuum.

Massachusetts proved something important in 2006: major reform is possible when leaders are willing to act, compromise, and build toward a common goal. The next chapter will require that same seriousness of purpose—this time focused less on expanding coverage and more on making the system work for the people and providers relying on it every day.

That work is already underway—in the rooms where the future of care is being shaped.