Despite the hopes of legislators, the program did not decrease total spending on healthcare or utilization of emergency medical services for primary care issues.

EMTALA requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay.

EMTALA is therefore considered an "unfunded safety net program" for patients seeking care at the nation's emergency rooms.

[12][13] As a result of the 1986 EMTALA legislation, hospitals across the country faced unpaid bills and mounting expenses to care for the uninsured.

[16] It was predicted that implementation of the 2006 Massachusetts healthcare insurance reform law would result in almost complete elimination of the need for this fund.

In 2006, MIT economics professor Jonathan Gruber predicted that the amount of money in the "free care pool" would be sufficient to pay for reform legislation without requiring additional funding or taxes.

[17] In November 2004, political leaders began advocating major reforms of the Massachusetts health care insurance system to expand coverage.

Under the existing waiver, the state was receiving $385 million in federal funds to reimburse hospitals for services provided to the uninsured.

The meeting resulted in Thompson signing a Medicare waiver that would redirect money that previously went to treat uninsured patients at safety net hospitals to near-universal health insurance coverage as proposed by Travaglini.

The legislature made a number of changes to Governor Romney's original proposal, including expanding MassHealth (Medicaid and SCHIP) coverage to low-income children and restoring funding for public health programs.

[26][27] The enacted statute, Chapter 58 of the Acts of 2006, established a system to require individuals, with a few exceptions, to obtain health insurance.

[29] The Division of Health Care Finance and Policy defined by regulation what contribution level meets the "fair and reasonable" test in the statute.

First, employers are deemed to have offered "fair and reasonable" coverage if at least 25% of their full-time workers are enrolled in the firm's health plan.

Beginning in 2008, the penalty is half the cost of the lowest available yearly premium which will be enforced as an assessed addition to the individual's income tax.

[35] Beginning July 2007, the Connector offered reduced benefit plans for young adults up to age 26 who do not have access to employer-based coverage.

[37] Prior to that 2010 change, under the Massachusetts law, residents buying healthcare insurance individually could do so at any time, even—theoretically—as being admitted to a hospital or entering an emergency room.

[41] Also effective in 2006, the Connector Board set premium levels and copayments for the state subsidized Commonwealth Care plans.

The United States Census Department shows a higher percentage of uninsured for the same years but a similar trend line.

In the early years of the implementation of the law, approximately 2% of those eligible were determined not to have had access to affordable insurance, and a small number opted for a religious exemption to the mandate.

The number of people with group insurance in Massachusetts held steady at around 4,400,000 since passage of the health care reform law, according to the DHCFP.

[citation needed] A study published in The American Journal of Medicine, "Medical Bankruptcy in Massachusetts: Has Health Reform Made a Difference?

", compared bankruptcy filers from 2007, before reforms were implemented, to those filing in the post-reform 2009 environment to see what role medical costs played.

"[54] In 2010, The Boston Globe reported that more than a thousand people in Massachusetts had "gamed" the mandate/penalty provision of the law since implementation by choosing to be insured only a few months a year, typically when in need of a specific medical procedure.

On the average, the Globe reported, these part-time enrollees were paying $1,200–$1,600 in premiums over a few months and receiving $10,000 or more in healthcare services before again dropping coverage.

"[57] A study by the fiscally conservative Beacon Hill Institute was of the view that the reform was "responsible for a dramatic increase in health care spending," however.

[58] In 2012, the Blue Cross Foundation of Massachusetts funded and released research that showed that the 2006 law and its subsequent amendments – simply in terms of measuring the state-budget effect on the uncompensated care pool and funding subsidized insurance had cost approximately $2 billion in fiscal year 2011 versus approximately $1 billion in fiscal year 2006.

[64] A 2014 study found that the reform was associated with "significant reductions in all-cause mortality and deaths from causes amenable to health care.

[citation needed] At the start of the Affordable Care act open enrollment at the end of 2013, there was a major technical failure, and the MA Health Connector Software did not work at all.

In November 2016, MassHealth received a federal Medicare waiver that allowed it to transition from fee-for-service payment to the use of accountable care organizations, expected to begin operation in December 2017.

[73] This expanded the similar One Care prevention-oriented program for Massachusetts patients who were enrolled in both Medicare and Medicaid, or had disabilities or very low income.