Title: Clark v. Attorney General
Citation: N/A
Docket Number: SJC-13238
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: June 15, 2022

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SJC-13238 
 
LORY-SAN CLARK & another1  vs.  ATTORNEY GENERAL & others.2 
 
 
 
Suffolk.     May 2, 2022. - June 15, 2022. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Kafker, Wendlandt, 
& Georges, JJ. 
 
 
Initiative.  Dentist.  Insurance, Rate setting.  Constitutional 
Law, Initiative petition.  Attorney General. 
 
 
 
 
Civil action commenced in the Supreme Judicial Court for 
the county of Suffolk on February 7, 2022. 
 
 
The case was reported by Lowy, J. 
 
 
 
Thaddeus Heuer (Andrew London & Seth Reiner also present) 
for the plaintiffs. 
 
Adam Hornstine, Assistant Attorney General (Anne Sterman & 
Michael MacKenzie, Assistant Attorneys General, also present) 
for the defendants. 
 
Matthew R. Perry for the interveners. 
 
M. Patrick Moore, Jennifer Grace Miller, & Ryan P. McManus, 
for America's Health Insurance Plans, Inc., & another, amici 
curiae, submitted a brief. 
 
 
1 Wendy Sutter. 
 
2 Secretary of the Commonwealth; Committee on Dental 
Insurance Quality, Mouhab Rizkallah, Robert Petrosino, Andrew 
Chase, Patricia Brown, and Laura Rizkallah, interveners. 
2 
 
 
 
CYPHER, J.  An initiative petition signed by at least ten 
registered voters, entitled "Initiative Petition for a Law to 
Implement Medical Loss Ratios[3] for Dental Benefit Plans," was 
submitted to the Attorney General and numbered by her as 
Initiative Petition 21-13.  On September 1, 2021, the Attorney 
General certified to the Secretary of the Commonwealth 
(Secretary) that Initiative Petition 21-13 was in proper form 
for submission to the people; that it was not, either 
affirmatively or negatively, substantially the same as any 
measure that had been qualified for submission or submitted to 
the people at either of the two preceding biennial State 
elections; and that it contained only subjects that were related 
or mutually dependent and that were not excluded from the 
initiative process pursuant to art. 48, The Initiative, II, § 2, 
of the Amendments to the Massachusetts Constitution. 
In accordance with the requirements of art. 48, the 
Attorney General prepared a "fair, concise summary" of the 
measure proposed by Initiative Petition 21-13 and transmitted 
 
 
3 A medical loss ratio is the proportion of premium revenues 
that an insurance carrier spends on clinical or patient services 
as opposed to administrative costs.  See Massachusetts Center 
for Health Information and Analysis, Annual Report Series 2015:  
Performance of the Massachusetts Health Care System, 
Massachusetts Medical loss Ratios 1 (2015), 
https://www.chiamass.gov/assets/docs/r/pubs/15/MLR-Brief-
2015.pdf [https://perma.cc/JFF2-TYD8]. 
3 
 
that summary to the Secretary with the September 1 certification 
letter.  The proponents of Initiative Petition 21-13 then filed 
it with the Secretary.  Following receipt of the summary and 
certification from the Attorney General, the Secretary prepared 
blank signature collection forms and provided them to proponents 
for circulation to members of the public.  On December 22, 2021, 
the Secretary's elections division sent a letter informing the 
proponents of Initiative Petition 21-13 that a sufficient number 
of certified signatures had been submitted pursuant to art. 48, 
The Initiative, II, § 3, as amended by art. 74 of the 
Amendments, and art. 48, The Initiative, V, § 2, as amended by 
art. 81 of the Amendments.  The Secretary submitted Initiative 
Petition 21-13 to the clerk of the House of Representatives on 
January 28, 2022.  See 2022 House Doc. No. 4378. 
 
Thereafter, two registered voters commenced an action in 
the county court challenging the Attorney General's 
certification of Initiative Petition 21-13.  They allege that 
the measure is not in compliance with the requirement that an 
initiative petition "contain[] only subjects . . . which are 
related or which are mutually dependent," art. 48, The 
Initiative, II, § 3, as amended by art. 74, and request that the 
Secretary be enjoined from placing the measure on the ballot.  
Five registered voters who are licensed dentists, along with the 
Committee on Dental Insurance Quality, of which they are members 
4 
 
and which was organized by them to sponsor Initiative Petition 
21-13, moved to intervene as defendants, and their motion was 
allowed.  A single justice reserved and reported the case to the 
full court on a statement of agreed facts.  We conclude that 
Initiative Petition 21-13 does not contain unrelated subjects 
and that the Attorney General's certification therefore complied 
with art. 48.4 
The proposed law.  If passed into law, Initiative Petition 
21-13 would establish a new G. L. c. 176X (proposed chapter), 
which would apply to all dental benefit plans in place on or 
after January 1, 2024, and which would be effectuated by 
regulations promulgated by October 1, 2023.  The proposed 
chapter would be comprised of four sections.  Section 1 would 
create definitions for various terms used therein, and § 4 
specifically would exclude from the chapter's requirements 
"dental benefit plans issued, delivered or renewed to a self-
insured group or where the carrier is acting as a third-party 
administrator." 
 
Section 2 of the proposed chapter would create a framework 
in which the commissioner of insurance (commissioner), through 
the adoption of relevant regulations, would review and approve 
dental benefit policies, rate changes, and plan profitability as 
 
 
4 We acknowledge the amicus brief of America's Health 
Insurance Plans, Inc., and American Council of Life Insurers. 
5 
 
reflected by a medical loss ratio (MLR).  Dental insurance 
carriers would be required to submit to the commissioner 
financial information, including "the current and projected 
[MLR] for plans" and "the components of projected administrative 
expenses."  The commissioner would be required to adopt 
regulations under which dental insurance carriers must file 
annual base rates and group rating factors for their plans, 
which would be disapproved if rate changes were "excessive, 
inadequate, or unreasonable" or group rating factor changes were 
"discriminatory or not actuarially sound." 
Section 2 sets forth three situations in which the 
commissioner would be required to presumptively disapprove an 
insurance carrier's rates as "excessive":  first, if the 
insurer's administrative expense loading component5 increases by 
a greater percentage than the dental services consumer price 
index6 for the most recent calendar year; second, if a carrier's 
 
5 "Administrative expense loading component" refers to the 
amount included in an insurance premium to cover the carrier's 
administrative and maintenance costs.  Cf. Massachusetts 
Division of Insurance, Health Coverage Policy Filing Guidance 
2012-C (May 16, 2012) (explaining calculations for determining 
administrative expense loading for health insurance plans 
subject to G. L. c. 176J). 
 
6 The United States Bureau of Labor Statistics reports 
national consumer price indices that measure the average change 
over time in the prices paid by urban consumers for particular 
goods and services, including dental services.  See United 
States Bureau of Labor Statistics, Consumer Price Index, 
Measuring Price Change in the CPI:  Medical Care, 
6 
 
contribution to surplus7 exceeds 1.9 percent; and third, if a 
carrier fails to meet a minimum MLR8 of eighty-three percent.  
Insurance carriers would be required to refund to covered 
individuals and groups excess premiums in the amount necessary 
to return the plan's MLR to eighty-three percent, unless the 
commissioner determines that issuance of refunds would 
financially impair the insurance carrier.  If the commissioner 
disapproves of a proposed rate change, the insurance carrier may 
contest this decision at a hearing. 
 
Section 3 of the proposed chapter would require dental 
insurance carriers timely to submit detailed annual financial 
statements to the Division of Insurance (division),9 which would 
 
https://www.bls.gov/cpi/factsheets/medical-care.htm 
[https://perma.cc/J3C6-4WPY]. 
 
 
7 Carriers are required to maintain a certain amount of 
"surplus," the excess of assets over the sum of capital and 
liabilities.  See G. L. c. 175, § 48.  A carrier's contribution 
to surplus is an amount included in a premium to establish and 
maintain the insurer's surplus. 
 
 
8 Initiative Petition 21-13 does not propose a definition of 
the term "medical loss ratio."  This ratio generally represents 
the proportion of insurance premiums directed towards patient 
care.  See note 3, supra. 
 
 
9 The information that insurance carriers would be required 
to submit in such reports includes:  "(i) direct premiums earned 
. . . [and] direct claims incurred . . . ; (ii) medical loss 
ratio; (iii) number of members; (iv) number of distinct groups 
covered; (v) number of lives covered; (vi) realized capital 
gains and losses; (vii) net income; (viii) accumulated surplus; 
(ix) accumulated reserves; (x) risk-based capital ratio . . . ; 
(xi) financial administration expenses . . . ; (xii) marketing 
7 
 
make such statements available to the public.  If a carrier's 
risk-based capital ratio -- the amount of capital retained as a 
basis of support for the degree of risk associated with its 
company operations and investments, measured across all medical 
and dental plans -- were to exceed 700 percent, a public hearing 
would be held at which the carrier would be required to submit 
testimony on its over-all financial condition, the continued 
need for surplus, and how, and in what proportion to the total 
surplus, it planned to dedicate the surplus to reducing costs or 
improving quality for consumers.  The division would be required 
to issue a report on the results of such a hearing. 
Discussion.  1.  Standard of review.  We review de novo the 
Attorney General's certification of an initiative petition as 
compliant with art. 48.  See Weiner v. Attorney Gen., 484 Mass. 
687, 690 (2020), citing Abdow v. Attorney Gen., 468 Mass. 478, 
487 (2014).  "At the same time, we acknowledge the firmly 
 
and sales expenses . . . ; (xiii) distribution expenses . . . ; 
(xiv) claims operations expenses . . . ; (xv) dental 
administration expenses . . . ; (xvi) network operational 
expenses . . . ; (xvii) charitable expenses . . . ; (xviii) 
board, bureau or association fees; (xix) any miscellaneous 
expenses described in detail by expense, including an expense 
not included in (i) to (xviii), inclusive; (xx) payroll expenses 
and the number of employees on the carrier's payroll; (xxi) 
taxes, if any, paid by the carrier to the [F]ederal government 
or to the commonwealth; and (xxii) any other information deemed 
necessary by the commissioner."  Additional information would be 
required from insurance carriers that administer services to one 
or more self-insured groups, including detailed information 
pertaining to self-insured customers. 
8 
 
established principle that art. 48 is to be construed to support 
the people's prerogative to initiate and adopt laws" (quotations 
and citation omitted).  Weiner, supra. 
2.  Relatedness.  "Article 48, The Initiative, II, § 3, as 
amended by art. 74, requires the Attorney General to certify 
that a proposed measure 'contains only subjects . . . which are 
related or which are mutually dependent' before the measure can 
be placed on the ballot."  Weiner, 484 Mass. at 691.  The 
plaintiffs argue that the provisions of Initiative Petition 21-
13 address two distinct policy goals that are unrelated, namely, 
the creation of a mandatory minimum MLR for dental benefit plans 
(§ 2) and insurer transparency through mandatory comprehensive 
financial disclosures (§ 3).  As discussed infra, we disagree. 
"There is no single 'bright-line' test for determining 
whether an initiative meets the related subjects requirement."  
Hensley v. Attorney Gen., 474 Mass. 651, 657 (2016), citing 
Abdow, 468 Mass. at 500.  "We have said that 'the related 
subjects requirement is met where one can identify a common 
purpose to which each subject of an initiative petition can 
reasonably be said to be germane'" (quotation omitted).  Weiner, 
484 Mass. at 691, quoting Hensley, supra.  Nevertheless, "[t]his 
purpose 'may not be so broad as to render the relatedness 
limitation meaningless'" (quotation omitted).  Weiner, supra, 
9 
 
quoting Carney v. Attorney Gen., 447 Mass. 218, 225 (2006), 
S.C., 451 Mass. 803 (2008). 
Accordingly, "relatedness cannot be defined so broadly that 
it allows the inclusion in a single petition of two or more 
subjects that have only a marginal relationship to one another, 
which might confuse or mislead voters, or which could place them 
in the untenable position of casting a single vote on two or 
more dissimilar subjects."  Abdow, 468 Mass. at 499.  "At the 
same time, if we construe the relatedness requirement too 
strictly, we risk limiting initiative petitions to a single 
subject, a requirement rejected by the constitutional convention 
that approved art. 48."  Weiner, 484 Mass. at 691, citing Abdow, 
supra.  We balance these considerations by asking two questions: 
"First, '[d]o the similarities of an initiative's 
provisions dominate what each segment provides separately 
so that the petition is sufficiently coherent to be voted 
on "yes" or "no" by the voters?'  Second, does the 
initiative petition 'express an operational relatedness 
among its substantive parts that would permit a reasonable 
voter to affirm or reject the entire petition as a unified 
statement of public policy'?" (Citations omitted.) 
 
Hensley, 474 Mass. at 658.  "We have not construed [the related 
subjects] requirement narrowly nor demanded that popular 
initiatives be drafted with strict internal consistency."  
Mazzone v. Attorney Gen., 432 Mass. 515, 528-529 (2000). 
The Attorney General argues that, viewed in its totality, 
Initiative Petition 21-13 "would create an integrated regulatory 
10 
 
scheme that would comprehensively address dental insurance rates 
that are excessive, inadequate, or unreasonable" in light of the 
benefits afforded to policyholders, and that all of the 
provisions of the proposed chapter are designed to advance this 
common purpose.  We agree.  Section 2 would empower the 
commissioner to approve dental benefit policies and requires the 
commissioner to adopt regulations regarding eligibility; collect 
information regarding plans' current and projected MLRs, 
administrative expenses, and financial information; disapprove 
an insurer's proposed rates, subject to a hearing, in prescribed 
circumstances; and hold public hearings if a carrier's risk 
based capital ratio exceeds 700 percent.  Section 2 therefore 
would establish much of the regulatory framework within which 
the commissioner is to carry out the duty of regulating dental 
benefit plans. 
Unlike the information that the commissioner is required to 
collect under § 2 (b), carriers would be required by § 3 (e) to 
disclose entity-wide financial information across all of their 
lines of business, not just their dental benefits plans.  
According to the plaintiffs, this difference, along with the 
presence of a specific reporting provision in § 2, demonstrates 
that the proposed act's scheme for establishing and enforcing a 
minimum MLR can function without the comprehensive disclosures 
required by § 3 and thus that there is "no inherent connection" 
11 
 
between the establishment of a minimum MLR and the requirement 
of comprehensive annual disclosures. 
The argument is unavailing.  First, the common purpose of 
the two sections is apparent from the way they complement one 
another.  See Dunn v. Attorney Gen., 474 Mass. 675, 681 (2016) 
(provision banning inhumane confinement of farm animals and 
provision banning sale of out-of-State products from animals so 
confined served common purpose because latter provision 
protected Massachusetts farms in compliance with former 
provision by preventing retailers from selling out-of-State 
products that could be underpriced as result of practices 
prohibited in Commonwealth).  The disclosure and public hearing 
requirements of § 3 further the regulatory goals of the proposed 
act, and of the approval process laid out in § 2 specifically, 
by providing the commissioner with a comprehensive body of 
information on which to assess a carrier's compliance with the 
goals of reducing the cost of dental benefit plans or of 
improving the quality of care, patient safety, or efforts at 
cost containment.  That the petitioners chose to propose such a 
broad mechanism for monitoring compliance is not fatal to the 
measure.  See Abdow, 468 Mass. at 503 ("Provided the subjects 
are sufficiently related, the choice as to the scope of an 
initiative petition is a matter for the petitioners, not the 
courts"). 
12 
 
Second, § 3 permissibly "anticipates and addresses a 
potential consequence" of the regulation scheme to be adopted in 
§ 2 and, therefore, is operationally related to § 2.  Oberlies 
v. Attorney Gen., 479 Mass. 823, 832 (2018).  In Oberlies, an 
initiative petition proposed hospital staffing ratios designed 
to limit the number of patients assigned to each nurse and also 
prohibited facilities from reducing their remaining workforce as 
a result.  Id. at 831.  In concluding that the two provisions 
were operationally related, we observed that, if hospitals were 
required to hire additional nurses to meet the patient 
assignment limits, they might respond by eliminating other 
staff.  Id. at 832.  Because the workforce-reduction prohibition 
sought to preclude this consequence of the staffing ratio 
provision, we held that the two provisions were operationally 
related.  Id. 
Initiative Petition 21-13 likewise anticipates and 
mitigates a foreseeable consequence of prescribing a minimum MLR 
for dental benefit plan carriers with other lines of business.  
That is, by requiring financial reporting on an entity-wide 
basis, § 3 enables the commissioner to detect potential 
accounting abuses by carriers who may attempt, for example, to 
transfer overhead expenses from their dental insurance lines to 
other insurance lines in order to inflate artificially their 
MLRs for the dental insurance lines.  We long have held that 
13 
 
initiative petitions designed to account for consequences of 
their primary objectives pass the relatedness test.  See Weiner, 
484 Mass. at 692 (age-verification requirements for alcohol 
sales and increased funding for regulatory enforcement 
operationally related to lifting restrictions on licensing of 
alcohol sales); Oberlies, 479 Mass. at 832-833; Dunn, 474 Mass. 
at 681-682; Hensley, 474 Mass. at 659 (comprehensive scheme for 
legalizing cannabis, licensing and regulating cannabis-related 
businesses, and taxing retail sales of cannabis satisfied 
relatedness requirement because all provisions were "piece[s] of 
the proposed integrated scheme"). 
The plaintiffs' reliance on Oberlies and Gray v. Attorney 
Gen., 474 Mass. 638, 648 (2016), is misplaced.  In Oberlies, 479 
Mass. at 836-837, we held that a second initiative petition that 
was identical to the first, see supra, except for the inclusion 
of a provision requiring hospitals to make broad financial 
disclosures did not comply with art. 48's relatedness 
requirement.  We concluded that this requirement bore "only a 
marginal relationship" to the rest of the measure because the 
staffing ratios were mandatory and not related to a hospital's 
ability to pay additional nurses needed to comply with them, 
Oberlies, supra at 836, quoting Abdow, 468 Mass. at 499, and 
because the general goal of transparency had "no apparent 
connection" to the petition's purpose of ensuring patient safety 
14 
 
through adequate staffing, Oberlies, supra at 837.  In Gray, 
supra at 648, we similarly held that a provision in an 
initiative petition that would have required annual release of 
standardized testing questions and answers neither shared a 
common purpose with nor was operationally related to other 
provisions setting the substantive requirements for educational 
curricula.  The present case does not require the same 
conclusion.  Here, the financial disclosures required by § 3 
relate not to a separate, general goal of transparency but to 
the common purpose of enabling the commissioner to implement and 
monitor compliance with the new MLR scheme established by § 2. 
Conclusion.  We remand the matter to the county court for 
entry of a judgment declaring that the Attorney General's 
certification of Initiative Petition 21-13 was in compliance 
with the requirements of art. 48. 
So ordered.