April 6, 2026
A framed picture of Gov. Mitt Romney signing the landmark 2006 health care reform law, later signed by the governor and gifted to then-Rep. Ronald Mariano, remains on display in now-Speaker Mariano's office. (CommonWealth Beacon/Chris Lisinski)

SUPREME COURT JUSTICE Louis Brandeis’s 1932 observation that states can function as “laboratories of democracy” has been repeated so often that it borders cliché. And it still works: “a single courageous State may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”

So it was in Massachusetts on April 12, 2006, when Republican Gov. Mitt Romney signed “An Act Providing Affordable, Quality, Accountable Health Care,” with shorthand ID as Chapter 58 of that year’s laws. Rarely has the connection between a single state statute and a subsequent federal law—the Affordable Care Act, signed by President Barack Obama in March 2010—been so clear. Chapter 58’s signing locale, Boston’s historic Faneuil Hall, seemed a bit of puffery to me 20 years ago, and not so much today.

Like it or hate it, Chapter 58 mattered. The law followed through on its essential premise and promise to reduce uninsurance in Massachusetts to the lowest level anywhere in the nation. It also legitimized a bipartisan, implementable, and replicable model for what became Title I of the Affordable Care Act, resulting in the nation’s lowest uninsurance rate ever.

What did the law do? It had three main components: 1. Created a substantial new health insurance subsidy program for uninsured working folks who can’t get Medicare, Medicaid, or employer-sponsored coverage; 2. Established the Massachusetts Health Insurance Connector Authority, where those needing individual coverage can shop for a plan, purchase it, and enroll with confidence and security; 3. Created an individual mandate for those who can afford to purchase insurance (with tax penalties for non-compliance).

What’s most important to keep in mind on this 20th anniversary? Here are three essential observations, linking Chapter 58 and the subsequent ACA:

1. Passage and implementation of Chapter 58 was bipartisan, unlike the subsequent partisan process leading to the ACA’s passage.

Key supporters included Republicans Gov. Romney and President George W. Bush, who provided essential federal financing. Of equal importance were Democratic Massachusetts House Speaker Sal DiMasi and Massachusetts Senate President Bob Travaglini, both of whom led chambers with overwhelming Democratic majorities. Also, first among equals was Democratic US Senator Ted Kennedy, whom Romney brought into the process early.

Romney and Kennedy both urgently wanted to prevent a state health system financial catastrophe from an impending federal reduction in Medicaid payments to the state set to begin in 2005. As the process unfolded, both also perceived a national game-changing opportunity. Romney already had one eye on the 2008 presidential race and needed a major accomplishment in liberal Massachusetts to prove his effectiveness. Bush wanted to help a capable and moderate Northeast Republican. Meanwhile, Kennedy, state legislators, and advocates were eager to conquer the political Matterhorn of universal coverage.

The ACA process launched in 2008 with similar bipartisan hopes. In 2009, however, Republicans jettisoned cooperation as the pre-MAGA movement called the Tea Party threatened primary challenges to any Republican officeholders who supported “Obamacare.”

Final passage took place in March 2010 with zero Republican votes. The same day that Obama signed the law, 20 Republican state attorneys general filed a federal lawsuit to kill the entire ACA. Full repeal became a sine qua non for Republicans everywhere until 2017, when President Donald Trump’s effort to repeal and replace the ACA collapsed.

2. Chapter 58 was not only about money, though pretty close.

Between 2003 and 2008, I was executive director of the Massachusetts advocacy group Health Care for All (HCFA). We built a mighty coalition called Affordable Care Today (ACT) with 50-plus organizations, such as the Greater Boston Interfaith Organization and the Service Employees International Union. For us, this was a moral crusade.

Bush administration officials informed state leaders in 2004 that supplemental federal Medicaid money that had been coming to Massachusetts since 1997, $385 million yearly by 2004, would end. That looming hole stiffened everyone’s spine to find an alternative. Romney and Kennedy promised Bush universal coverage in one state, along with a mandate for individuals to buy insurance, something many Republicans had embraced and most Democrats dismissed. Health Care for All and the ACT coalition endorsed the mandate only if guaranteed health insurance was comprehensive and affordable. We got that in Chapter 58. The financial crisis had opened a window of opportunity for a historic advance.

In the later ACA process, money mattered too. Obama, House Speaker Nancy Pelosi, and Senate Majority Leader Harry Reid committed to passing historic coverage expansion, provided that total costs were revenue neutral for the feds, balanced by new taxes and cuts, and not exceeding $1 trillion over 10 years. When we priced the Massachusetts model, a federal version of it would have cost $1.6 to $2.5 trillion. So the insurance subsidies had to be less generous even though the ACA didn’t add one penny to the national debt. Later, in 2021 and 2022, Democrats were finally able to expand ACA affordability, though only through the end of 2025.

3. The Massachusetts Health Connector became a dynamic policy instrument.

The conservative Heritage Foundation gave Romney two ideas that he embraced as part of the 2006 reform law: the individual mandate and an “exchange” to enable consumers to purchase personal coverage via websites. Both ideas were advanced by Heritage policy director Stuart Butler, who departed from the organization in 2013 when his key ideas had become politically toxic for conservatives. Massachusetts launched its Connector in 2006 with immediate success.

In 2009, as the ACA was crafted in Congress, the insurance exchange idea became a key component. Senate and House Democrats disagreed over whether an insurance exchange should be nationally or state run. House Democrats insisted on one federal entity for everyone, like how the government runs traditional Medicare. Senators, more deferential to states, wanted them to have right of first refusal to create exchanges according to federal rules, with the Massachusetts Connector as the prototype.

The Senate prevailed, and immediately after passage, most states, red or blue, began establishing state exchanges. As Obamacare political warfare metastasized, however, Tea Party activists demanded that red states refuse to participate to delegitimize the ACA. All red states except Idaho withdrew.

When exchanges launched in the fall of 2013, the federal website and many state websites experienced a near-cataclysmic technology failure, nearly derailing the entire infrastructure. This triggered the withdrawal of some blue and purple states, leaving just 12 states running their own. Most of these, including Massachusetts, experienced troubled starts.

Since recovering from the shaky launch, state exchanges have become productive and valuable, far outperforming the one-size-fits-all healthcare.gov federal exchange, with more enrollees and lower premiums. Today 22 states run their own exchange, including red states such as Georgia, with more coming. Massachusetts set the model and continues to be among the best with the nation’s lowest rate of uninsurance, at between 2 and 3 percent.

* * *

In 2014, exchange enrollment began with 8 million covered lives nationally. By 2020, those numbers reached 12 million. With enhanced subsidies starting in 2021 and 2022, enrollments reached 25 million in 2025. In the ongoing Trump 2.0 retrenchment, enrollments may decline to 20 million over several years—or not, depending on 2026 and 2028 federal election outcomes. The ACA’s Medicaid expansion added more than 20 million additional covered lives, though many of those also are now at risk because of Republican cutbacks.

All along the way, Massachusetts has remained at the vanguard of high-performing states whose coverage expansions excel nationally. Though our current system is far from perfect—and moving backwards now under Trump 2— our nation became a better and fairer society because of what so many in our state accomplished in 2006. In the end, it was about money and morality, too.

John E. McDonough is a professor of practice at the Harvard TH Chan School of Public Health in Boston. He was executive director of Health Care for All from 2003 to 2008. He worked on Sen. Ted Kennedy’s staff during the writing and passage of the Affordable Care Act. His next book, America’s Wrong Turn: US Healthcare in the Neoliberal Era, will be published in August by Johns Hopkins Press.