Reporter Kevin Sack of The New York Times wrote in a March 16 article that "the day of reckoning has arrived" for the Massachusetts health insurance experiment.

In 2006, the state passed a law mandating that all of its citizens must have health insurance and requiring individuals and employers to pay. It also created a new system of subsidies and overhauled the health insurance market with strict new regulations.

So far, nearly 60 percent of those newly insured are getting free or heavily-subsidized coverage, jointly funded by the state and by federal matching Medicaid dollars. Those not eligible for subsidies must purchase insurance or pay a fine of up to $1,068.

"Because Massachusetts now requires its residents to be insured, it cannot fall back on the strategy used by other states in hard times — to simply remove people from the public insurance rolls by restricting eligibility," Sack wrote.

The federal government last year approved an extension of Massachusetts’ Medicaid waiver, allowing the state to draw nearly $11 billion to fund the $21 billion program over the next three years. But this is not enough to finance its universal health coverage plan.

Last year, the state legislature passed new taxes and fees to make up the budget shortfall. It enacted a $1-per-pack increase in the cigarette tax and passed legislation calling for “contributions” of an additional $89 million, primarily from hospitals and insurers, to help close the budget gap.

In a desperate effort to rein in costs, Gov. Deval Patrick has expressed interest in regulating insurance premiums.

Sack referred to research by Prof. Alan Sager of Boston University, who calculated Massachusetts health spending is one-third more per person than the rest of the nation.

If stakeholders had understood what was coming — higher taxes and heavier regulation — perhaps they would not have signed on as readily.

As Sack put it, "Those who led the 2006 effort said it would not have been feasible to enact universal coverage if the legislation had required heavy cost controls. The very stakeholders who were coaxed into the tent — doctors, hospitals, insurers and consumer groups — would probably have been driven into opposition by efforts to reduce their revenues and constrain their medical practices."

There are other pressures on the provider side as well. Some safety-net hospitals say they still are treating a large number of people without health insurance, but the payments they receive for uncompensated care have been cut as part of the health reform deal.

The shortage of primary-care doctors is making it difficult in some parts of the state for people who are newly insured to find a doctor who will take new patients. Nearly half of internists are not accepting new patients, and waiting time to get an appointment has increased to nearly two months.

One resident complained: “Before, I was uninsured and couldn’t see a doctor. Then I made the sacrifice to buy insurance, but I still can’t find a doctor who will see me. So I still don’t get to see a doctor. It’s just costing me more now.”

Massachusetts had a head start on the rest of the country with a lower-than-average uninsured rate, and with cooperation from businesses, providers, and legislators on both sides of the aisle. Before proceeding with this model, the best advice for the rest of the country would be to see how Massachusetts addresses cost and other problems before going down the road of mandates on employers and individuals to provide and pay for increasingly expensive health insurance.

Reporter Kevin Sack of The New York Times wrote in a March 16 article that "the day of reckoning has arrived" for the Massachusetts health insurance experiment.

In 2006, the state passed a law mandating that all of its citizens must have health insurance and requiring individuals and employers to pay. It also created a new system of subsidies and overhauled the health insurance market with strict new regulations.

So far, nearly 60 percent of those newly insured are getting free or heavily-subsidized coverage, jointly funded by the state and by federal matching Medicaid dollars. Those not eligible for subsidies must purchase insurance or pay a fine of up to $1,068.

"Because Massachusetts now requires its residents to be insured, it cannot fall back on the strategy used by other states in hard times — to simply remove people from the public insurance rolls by restricting eligibility," Sack wrote.

The federal government last year approved an extension of Massachusetts’ Medicaid waiver, allowing the state to draw nearly $11 billion to fund the $21 billion program over the next three years. But this is not enough to finance its universal health coverage plan.

Last year, the state legislature passed new taxes and fees to make up the budget shortfall. It enacted a $1-per-pack increase in the cigarette tax and passed legislation calling for “contributions” of an additional $89 million, primarily from hospitals and insurers, to help close the budget gap.

In a desperate effort to rein in costs, Gov. Deval Patrick has expressed interest in regulating insurance premiums.

Sack referred to research by Prof. Alan Sager of Boston University, who calculated Massachusetts health spending is one-third more per person than the rest of the nation.

If stakeholders had understood what was coming — higher taxes and heavier regulation — perhaps they would not have signed on as readily.

As Sack put it, "Those who led the 2006 effort said it would not have been feasible to enact universal coverage if the legislation had required heavy cost controls. The very stakeholders who were coaxed into the tent — doctors, hospitals, insurers and consumer groups — would probably have been driven into opposition by efforts to reduce their revenues and constrain their medical practices."

There are other pressures on the provider side as well. Some safety-net hospitals say they still are treating a large number of people without health insurance, but the payments they receive for uncompensated care have been cut as part of the health reform deal.

The shortage of primary-care doctors is making it difficult in some parts of the state for people who are newly insured to find a doctor who will take new patients. Nearly half of internists are not accepting new patients, and waiting time to get an appointment has increased to nearly two months.

One resident complained: “Before, I was uninsured and couldn’t see a doctor. Then I made the sacrifice to buy insurance, but I still can’t find a doctor who will see me. So I still don’t get to see a doctor. It’s just costing me more now.”

Massachusetts had a head start on the rest of the country with a lower-than-average uninsured rate, and with cooperation from businesses, providers, and legislators on both sides of the aisle. Before proceeding with this model, the best advice for the rest of the country would be to see how Massachusetts addresses cost and other problems before going down the road of mandates on employers and individuals to provide and pay for increasingly expensive health insurance.