Just as the health care overhaul in Massachusetts is widely accepted as the model for the national bill upheld as constitutional Thursday by the US Supreme Court, it is also seen by many as a model and a caution for the necessary sequel to much broader insurance coverage: cost control.

Bringing almost everyone under the umbrella of health insurance is considered by advocates of the 2006 Massachusetts law, and of President Obamas 2010 plan, as the essential precondition for reining in medical expenses. All consumers, employers, hospitals, and insurers now abruptly, with the laws implementation, have a major stake in that goal.

But nothing about the journey is easy as six years experience in Massachusetts shows.

Consumers should not expect to see Obamas plan lead to lower medical bills, at least not anytime soon. What they can expect is a vigorous clash of interests, leading eventually, the hope is, toward accommodation and compromise.

That has been the Massachusetts story so far. With Governor Deval Patrick threatening the states robust health care industry with aggressive intervention, a patchwork coalition of hospitals, insurers, businesses, doctors, and lawmakers has been working to come up with ways to make care more affordable.

Some large teaching hospitals have signed contracts with insurers that call for lower fee increases than in the past. More than 1.2 million people about 1 in 5 residents are already covered by plans that put providers on a budget in an effort to restrain health spending. And insurers are offering more tiered plans that limit consumers choice of hospitals.

House and Senate leaders are privately negotiating over their two competing plans to control medical spending by tying it to the growth of the state economy. They hope to reach an agreement by the end of July, an agreement that Patrick must also sign on to.

Massachusetts, more than any other state, is having an aggressive dialogue about how to reduce the rate of growth in health care spending, said John McDonough, director of Harvards Center for Public Health Leadership, who helped craft the federal legislation. The health reform law created such a spotlight on the states health care system and right away, everybody business and insurers recognized the most destabilizing thing that could happen to undermine reform was if health care costs continued to spiral out of control.

To its advantage, Massachusetts already had the preexisting network of often competing interests that worked together in 2006 to bring about health reform, a coalition that does not exist on the national stage or in many other states.

The state also faced acute pressure to tackle the cost containment problem, which predated the 2006 reform law championed by then-governor Mitt Romney (although he has since renounced it as a flawed template for national legislation, and says he will repeal it, if elected). Massachusetts individual insurance premiums are the highest in the country, more than double the national average in 2010, according to the Kaiser Family Foundation, which tracks the data.

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