BOSTON – The goal was as audacious as it was simple: Plug the holes in Massachusetts' health care network without resorting to the politically nuclear option of a single government-funded program.
The result is a landmark insurance law praised as innovative, derided as a house of cards and touted by former Gov. Mitt Romney as he runs for president.
As of Sunday, nearly everyone in Massachusetts must be insured or face a series of increasing tax penalties.
The law won't result in universal coverage immediately, but the deadline is a critical mile marker.
"July 1 is really a call to action," said Leslie Kirwan, chairwoman of the Health Care Connector Authority Board, which oversees implementation of the law. "We are looking to insure people, not penalize them."
The law divides the population into three segments:
—The poorest, making less than the federal poverty level, are eligible for free care.
—People making slightly more, up to three times the federal poverty level, can enroll in state subsidized plans.
—Those making more than three times the federal poverty level — at least $30,630 for an individual and $61,950 for a family of four — can choose their own coverage from new, lower-cost private plans, if they aren't already insured through work.
Massachusetts' health care experiment could spur or slow health care reform efforts nationally depending on its success or failure, said Drew Altman, president of the Kaiser Family Foundation, which studies health policy.
Key to that success is whether average people embrace the idea of an "individual mandate" — the requirement that they obtain health care.
"It has huge implications for other states, but even more importantly for the push for health care reform building nationally," said Altman. "It's the first real-world test of this idea of an individual mandate. This idea is either going to build steam or lose a lot steam."
Amy Cassidy and her family have already taken advantage of the new law.
Cassidy, 38, provides day care and her husband runs a small flooring operation. Before the law, they were spending more than $1,200 a month on health care for themselves and their two small children.
Now, Cassidy said, they spend about $969 a month with a policy purchased through the Connector, a $250 savings.
"That's grocery money," she said. "But I still haven't had to use it yet. It hasn't been put to the test."
The state already has enrolled about 130,000 formerly uninsured people in health care plans, virtually all of them in the free or subsidized plans.
The far more challenging task is persuading the estimated 160,000 still uninsured residents not eligible for subsidized plans to pay monthly premiums. Even the lower cost plans can run several hundred dollars a month.
And while one recent poll found nine out of 10 residents were aware of the health care law, 49 percent said residents shouldn't be required to buy insurance.
Even some advocates are reserving judgment.
John McDonough, executive director of Health Care for All, said the group pushed to have all health care policies include drug coverage, something businesses fought. Under a deal, a drug mandate will kick in at the start of 2009.
McDonough said the group is monitoring businesses' reactions. Some employers are expected to boost benefits to hold on to workers and others to drop coverage, hoping workers will be eligible for state subsidized programs.
"It's really a multilayered question," McDonough said.
Eileen McAnneny, senior vice president of government affairs for Associated Industries of Massachusetts, said most businesses support the health care reform law, although some have been frustrated with the way it has been put into effect.
Companies with 11 or more workers must offer insurance or face annual fees of $295 per worker.
One way they can satisfy that requirement is to offer special accounts that allow employees to buy insurance with pretax dollars, but the regulations needed to let businesses create those accounts were only approved earlier this month.
"For all that to be up and ready by July 1 ... is a Herculean task," McAnneny said.
Insurance companies also have found the law challenging, according to Marylou Buyse, president of the Massachusetts Association of Health Plans.
"Insurers have worked very hard to put out attractive and affordable products," she said. "But if the new law is going to work in the long run we all have to address the fundamental issues driving health care costs."
The new state budget has $472 million to cover the subsidized plans, and Kirwan said that number could rise. It's hoped the state could phase out its so-called "free care" pool — money paid to hospitals for treating the uninsured — by moving people into insurance programs.
Kirwan said the state is in it for the long haul.
"There will be glitches in it and there will be gaffes at some point, but if we waited until every one of those things were nailed down, this would never get off the ground," Kirwan said.
On the Net:
Massachusetts Health Connector: http://www.mahealthconnector.org/