Celebrating the 20th Anniversary of Massachusetts Health Care Reform
With Medicaid and the ACA under pressure, sustaining coverage gains while tackling affordability will be the defining tests of the next era of reform.
Author: Patti Boozang
Editor: Amanda Eisenberg
tl;dr
Chapter 58 proved universal health coverage isn’t a dream — it’s a reality that Massachusetts achieved through: a clear mission to help, the political will of strong leadership across the public and private sectors, collaboration to craft pragmatic policy, strong implementation, and ongoing improvement over decades. It set the blueprint for national reform.
Medicaid is the throughline, and the engine: MassHealth anchored Massachusetts’ model, and Medicaid expansion powered the Affordable Care Act (ACA)’s biggest coverage gains, even as that role is increasingly threatened.
The next chapter of reform — in Massachusetts and nationally — is of equal urgency: with the ACA and Medicaid under pressure, progress will only hold — and improve — if leaders across the public and private sectors recommit to protecting the foundation and redesign health care and health care coverage around what people can actually afford.
The 80 Million Impact
I had the honor of joining leaders from across the country this week at Boston’s Faneuil Hall to celebrate the 20th anniversary of Massachusetts’ landmark health reform law.
It was more than a commemoration. It was a reminder — and, frankly, a challenge.
Standing in the same place where Chapter 58 was signed, with five governors spanning decades of leadership, I was struck not just by what Massachusetts achieved — but by how it did it. The gathering of Gov. Maura Healey (D) alongside former Govs. Deval Patrick (D), Mitt Romney (R), William Weld (R) and Michael Dukakis (D) was not just symbolic. It was a living example of something that feels increasingly rare: sustained, bipartisan commitment to solving big problems.
And it worked.
Massachusetts didn’t just expand coverage. It built a system — one that has consistently delivered near-universal coverage, integrated Medicaid (MassHealth) as a core pillar of that system, and proven that government, when it works well, can produce durable, life-changing results.
That success matters far beyond Massachusetts.
As former CMS Administrator Chiquita Brooks-LaSure made clear in her keynote remarks for the event, this state didn’t just inspire national reform — it made it possible. “What Massachusetts did here in 2006 made the ACA possible … In those moments, Massachusetts was the answer to the question: Is this even possible? And the answer … was yes.”
That framing is exactly right.
Massachusetts provided something Washington, D.C., had long lacked: a working model. It gave policymakers a blueprint — not a theory — for how to expand coverage, structure markets, and integrate Medicaid into a broader system of care.
But it also did something more important: It proved success was possible.
Medicaid: The Throughline from Massachusetts to the ACA
One theme that resonated throughout the event is the central role of Medicaid.
In Massachusetts, MassHealth was not a side program supporting reform. It was the foundation that made reform work. Chapter 58 explicitly expanded Medicaid eligibility and key benefits, while pairing those expansions with new subsidized coverage options through the Health Connector.
This was not incidental design. It was deliberate architecture.
Massachusetts understood that universal coverage could not be achieved through private markets alone. It required a strong public coverage backbone — one that could reach low-income residents, stabilize the system, and make coverage genuinely affordable.
And it worked. The 2006 reforms, including MassHealth expansion, were associated with:
A more than 50% reduction in the uninsured rate, helping Massachusetts achieve the highest coverage rate in the nation
Significant gains in access to care, including declines in unmet need and out-of-pocket burden Measurable improvements in both physical and mental health, alongside increased use of preventive services
Within just a few years, Massachusetts reached near-universal coverage — and has sustained it for two decades, with roughly 98% of residents insured today.
That success was not just about coverage numbers. It was about system design. MassHealth anchored affordability. It supported providers — particularly safety net hospitals and community health centers — and enabled the kind of community-based outreach and enrollment infrastructure that brought people into coverage and kept them there. In other words: Medicaid made universal coverage real, not theoretical.
The Next Chapter: Harder, But No Less Necessary
If the first chapter of reform was about expanding coverage, the next chapter is more complex. It’s about sustaining coverage gains, yes. But affordability is now the defining challenge for Massachusetts and the country.
Premiums, deductibles, and out-of-pocket costs are straining families, employers, and state budgets. Coverage alone is no longer enough. And as was true of Massachusetts reform through Chapter 58, progress now depends on collaboration — across government, providers, payers and communities. It requires breaking down siloes, aligning incentives and designing systems around people. Massachusetts has done this before. But doing it again — in a more polarized, fiscally constrained, and complex environment — will be harder.
Those leaders who built, defended and advanced Massachusetts health care reform and the ACA reminded me what matters in these moments. There was a sense in the room that went beyond nostalgia. It was something closer to resolve. A recognition that the progress of the past 20 years is not guaranteed. That it can be weakened — or even reversed — without sustained attention and leadership. And also, importantly, it can be protected, built upon and improved.
My Manatt Health colleague Mandy Cohen, in her remarks at the Healthcare for All Massachusetts Gala earlier this month, captured the broader context with striking clarity. “Moments like these don’t just test systems. They reveal who is willing and able to lead into the future.”
This moment is an opportunity. That is the real lesson of Chapter 58: Reform is not a one-time achievement. It is an ongoing commitment. That’s true for Massachusetts and the nation.
The Bottom Line
Twenty years ago, Massachusetts changed what Americans believed was possible. It showed that universal coverage could be achieved — not through ideology, but through pragmatic design, bipartisan leadership and a relentless focus on people. It also demonstrated something equally important: Medicaid is not peripheral to that vision. It is central to it. The ACA carried that lesson forward, with Medicaid expansion driving much of the nation’s coverage gains and reshaping expectations about what health coverage should provide. Today, both Medicaid and the ACA face renewed pressure. That makes the lesson of Massachusetts more relevant — and more urgent — than ever. Progress is possible.