A screenshot of the Health Connector home page. (Image by Yael Mazor.)

TWENTY YEARS AGO this month, Massachusetts set out to tackle one of the most vexing health care policy challenges of its time – the problem of the uninsured. A solution to the problem had long eluded state policymakers, and, although incremental progress had been made over the years, the number of uninsured was growing yet again.

But finally, a window of opportunity opened, and a carefully crafted and hard-negotiated solution emerged.  Chapter 58 of the Acts of 2006 was signed into law by Gov. Mitt Romney, representing a leap forward that changed the course of history in Massachusetts and later — given that its architecture and results influenced the Affordable Care Act – the entire United States.

Its success in achieving a dramatic reduction in uninsurance was swift. By 2008, the number of working-age adults in Massachusetts without health insurance had fallen by 70 percent. Today, the state has the lowest rate of uninsured residents in the country.

Chapter 58 was comprised of a range of discrete policy components, rooted in a principle of shared responsibility, that would all work together to bring the state’s uninsured individuals into the ranks of the insured, including a new requirement that all adults carry health insurance.

But where would they get covered?

Some of the uninsured would sign up for employer-based coverage. Others would join the state’s Medicaid program, MassHealth, having become eligible as additional categories of residents would now newly qualify. But Chapter 58 also created an entirely new kind of organization to facilitate enrollment in coverage – one that would make coverage available to people of any income level who weren’t already able to enroll through another source. This new organization would be nation’s first health insurance “exchange” or marketplace. It would be called the Health Connector.

There had never been an organization in Massachusetts, or the nation, quite like the Health Connector, with its complex set of operational and policy responsibilities. Since this organization would facilitate enrollment in coverage for people regardless of whether they qualified for financial assistance, it would sit at the interface between the commercial insurance market and government programs like MassHealth.

The Health Connector had to quickly establish a method for facilitating the sale of carefully vetted private commercial insurance products for residents earning too much to qualify for subsidies, while simultaneously facilitating the procurement and administration of publicly financed means-tested health insurance benefits for individuals with lower incomes. It would serve both the nongroup (individual) and small group markets, which had been newly merged.

The Health Connector would be an operation responsible for handling hundreds of millions of dollars annually, comprised of premium payments from covered individuals and state premium and cost-sharing subsidies, along with coordination of federal monies.

It would administer and manage all the business dimensions of a complex service organization, including call centers, procurements, complex technology systems, and back-end system vendors. It would be responsible for establishing and maintaining awareness among the Massachusetts public about the new law and the requirement that people carry health insurance, and for promoting itself as a trusted destination for health coverage to the public at large and, particularly, in communities that had been disproportionately uninsured.

On top of these demanding operational duties, this organization would also, in parallel, be responsible for making enormously complex and high-stakes policy decisions, with its board of directors charged with answering the questions delegated to it by a smart but flexible statutory framework. What, for example, would the Health Connector decide would be considered “affordable” for the purposes of the individual mandate that 5 million Massachusetts adults would now be subject to? What kinds of benefits would insurance need to include in order to satisfy “minimum creditable coverage” standards for those same 5 million adults?

I’ve long admired the policy smarts and business savvy that the Health Connector’s foundational architects – both those who penned its visionary statutory charge and its early administrative and board leaders doing the hard work of implementation – brought to the work of conceiving this organization. But as we approach the 20th birthday of the Health Connector, where I serve as executive director, and reflect on the longer arc of this organization and Chapter 58’s impact, I am especially struck by the foresight of the resilience and flexibility that was so intentionally built into what the Health Connector was created to do.

The Health Connector is designed to be outwardly flexible: to be a turnkey and trustworthy coverage source and solution for people from all walks of life, people who might otherwise fall through the cracks of an insurance market that (actuarially speaking) strongly prefers large groups.

We are expected to meet the coverage needs of a dynamic population in a dynamic market. And, by making us an independent authority with a diverse board of directors appointed by both the governor and the attorney general, the architects of the Health Connector also envisioned an organization with inward flexibility – one that could move faster, reach further, and pivot more freely as a business entity.

This is an organization that was designed to be on the move and to innovate. The contours of our 20-year history prove that our architects were right to think the Health Connector would need to flex and move and bend; our history shows how we’ve evolved and adapted the way our programs and policies work to meet the needs of the people we’re here to serve.

We’ve held close the core framework of Chapter 58. But thanks to the resilient and adaptive scaffolding it provided, over the years we’ve taken action to retool our programs to embrace the Affordable Care Act; expand financial assistance when new resources made it possible; revise how minimum creditable coverage is defined to meet evolving public health needs and market dynamics; transform the way we conduct outreach and community engagement to better meet the needs of the public; and optimize our service models to ensure a best-in-class experience for our applicants and enrollees.

Each time we reach for the next rung, the trust that the architects of Chapter 58 placed in the Health Connector and those of us continuing to implement their vision echoes across the decades.

The 20th anniversary of Chapter 58, including its creation of an experimental organization, the Health Connector, provokes reflectiveness and pride for so many of us who’ve worked to implement, protect, and advance the spirit and the particulars of what this law set out to do. That work has resulted in the Health Connector having covered over 1.5 million residents since its creation and in Massachusetts achieving and maintaining the highest rate of insurance in the nation, with roughly 97 percent of our residents covered.

We now find ourselves in a uniquely challenging moment for our health care system and for the cause of health reform, as we face continued cost and affordability challenges and federally driven setbacks in Affordable Care Act funding and policy.

Those of us carrying the vision of Chapter 58 and the Health Connector forward into its third decade must now dig deep to chart the path forward, solve new and vexing problems, take chances, and fight for the people we’re here to serve.

The resilience-based framework Chapter 58 provided will allow us to springboard to solutions not yet imagined – just as our founding architects would have hoped.

Audrey Morse Gasteier is executive director of the Massachusetts Health Connector.