The Congressional debate leading to the enactment of federal health care reform legislation (the Patient Protection and Affordable Care Act or the "PPACA") paid close attention to the structure and results of access reform legislation enacted in Massachusetts in 2006 in Chapter 58 of the Acts of 2006 ("Chapter 58"). Many of the key access reform elements of the PPACA mirrored the most notable components of Massachusetts's reform.

In crafting the PPACA, the Administration and Congress had to consider the effect on the federal deficit of the coverage expansion and other benefits provided for under the legislation. Congressional Budget Office (CBO) scoring of each proposal during the legislative process became a focus of anticipation, debate, and controversy. Other, more political concerns became predominant, especially relating to increased federal spending on health care expected to accompany access expansion and subsidies so soon after the substantial deficit spending authorized in the American Restoration and Reinvestment Act of 2009. To obtain an acceptable CBO score, the PPACA contained certain quantifiable effects on the federal budget. These included tax increases, reductions in provider payments (especially Medicare inpatient hospital payments), and a significant decrease in payments for disproportionate share hospitals. These reductions assumed, presumably, that the affected hospitals would benefit from the anticipated increase in the number of previously uninsured patients who would access their services through non-Medicare benefit coverage. In addition the PPACA provided for other changes to Medicare payment policies that were intended to reduce costs while also improving quality, such as those relating to hospital-acquired conditions and readmissions.

The PPACA addressed efforts to achieve broader delivery and payment reform only in relatively limited ways, in part due to the political compromises needed to achieve enactment of such a broad and complex piece of legislation. But the PPACA also recognized that there are limits to seeking major changes in the overall structure of, and payment for, health services through using only Medicare.

By contrast, the political coalition that came together in 2005 and 2006 in Massachusetts to secure enactment of Chapter 58 made what seems to have been an intentional decision primarily to address access and to forego dealing with the necessarily concomitant issue of reducing cost increases likely generated by expanded access. Supporting this political consensus was the already high level of per capita state spending on health care in Massachusetts prior to enactment of Chapter 58, and the then federal Administration's support for the reform's philosophical underpinning: to move people from reliance on the limited benefits available through the Commonwealth's uncompensated care pool to broader reliance on insurance coverage