Massachusetts built the insurance exchange that became the ACA

Massachusetts faced a growing uninsured population and a free-care pool that confined poor residents to one hospital. Individual insurance was the problem: the sickest bought in, the young and healthy stayed out, and premiums rose.

The 2006 reform attacked all three parts at once. A public Connector pooled individual and small-group buyers; subsidies covered those up to 300% of the poverty level; an individual mandate required people to insure or pay a penalty; and a modest employer assessment nudged firms to offer coverage.

Pooling was the move. Instead of a lone consumer facing the market, the Connector bought coverage for thousands at once and steered subsidized people into it.

From 2006 to 2010, at the height of a national recession, Massachusetts cut its non-elderly uninsured from 602,000 (10.9%) to 356,000 (6.3%) while the national share rose. The hybrid — exchange plus mandate — became the blueprint for the Affordable Care Act.