By the summer of 2008, less than two years after Massachusetts’ health reform law became effective, only 2.6 percent of state residents were uninsured—the lowest proportion ever recorded for any state. Like Massachusetts, other states and various federal programs have tried to increase coverage by providing subsidies for uninsured residents with low incomes, but most have fallen short. This begs the question, why has Massachusetts been so successful? A new study by the Robert Wood Johnson Foundation-funded State Health Access Reform Evaluation (SHARE) initiative answers this question and explains how national reforms can use similar methods to avoid the pitfalls that have plagued other coverage expansions.

Based on interviews with policymakers, stakeholders, advocates, and others, as well as a review of published reports, Urban Institute authors Stan Dorn, Ian Hill, and Sara Hogan identified key factors that have played a central role in helping Massachusetts enroll so many eligible, low-income uninsured, including the following:

• Within 15 months of implementation, roughly one out of four newly insured state residents received subsidized coverage based on state data about household income, without any need to file traditional application forms.
• A single application form and a single system of eligibility determination served multiple subsidy programs, making enrollment simple and seamless for consumers.
• More than half of all successful applications for subsidized coverage were completed for consumers by community-based organizations and health care providers.

The authors suggest that for future reforms at either the national or state level to accomplish the basic objective of enrolling the low-income uninsured into health insurance, it will be important to incorporate lessons from Massachusetts into the design of coverage expansion.