BOSTON (AP) — When Massachusetts adopted its landmark health care law in 2006, the goals were ambitious and the potential solutions complex.
More than 90 percent of its residents already had health insurance, but the state hoped to cover nearly everyone by plugging as many holes as possible in its system, short of a so-called single payer option.
What resulted was a state law that became the blueprint for the 2010 federal Affordable Care Act signed by President Barack Obama.
Now, as other states begin grappling with the intricacies of the federal health care overhaul, many are looking for lessons from the largely successful Massachusetts model as well as from its limitations and remaining challenges.
Officials from Wisconsin, Minnesota, Colorado, West Virginia and Rhode Island have worked with Jonathan Gruber, an MIT economics professor who helped craft both the state and federal laws, to set up their exchanges.
What are they getting in return? A guide to a law that has resulted in more people visiting doctors, more employees getting coverage through their jobs and an increase of insured residents to 98 percent, far above the national average, including virtually all children and senior citizens. That's an additional 400,000 people with insurance since the law took effect.
Other states would also do well to note the difficulties resulting from the law: a shortage of primary care doctors, which is expected to be an unintended consequence of the federal law, and an increase in the number of procedures that insurers were required to pay for, which raised costs.
Massachusetts' law, written for a state that is relatively richer and more highly educated than others, won't be a perfect fit for any other state, of course. But the experiences resulting from the law have played out on personal levels universal to all 50 states — in doctor's offices, at kitchen tables and in human resource departments.
Among those most directly affected were the uninsured who had relied on care from emergency rooms, the cost of which was borne by hospitals and taxpayers. The law's top objective was to get those people into health plans. A system was created to subsidize care for people earning less than three times the poverty level and design lower-cost private plans for those earning more.
For Valerie Spain, the overhaul proved to be a lifesaver. She was underemployed in 2011 and no longer able to extend her insurance coverage from her previous job, an option that had been costing her $550 a month.
The 57-year-old former operations manager found insurance through the new subsidized program. She pays a $20 co-pay for visits to her doctor's office but no premiums.
Without the insurance, Spain said she doesn't know how she would keep her diabetes under control.
"I'm sure I would have had to be rationing my medication," she said.
The influx of such new patients is good for those who finally have insurance, but it's been tough on doctors, said Richard Dupee, a 67-year-old primary care doctor and chief of geriatrics service at Tufts Medical Center. He said many have declined to accept patients on the subsidized plans because the reimbursement rates are not as good as private plans.
"If you nickel and dime the doctors, they are not going to take the insurance," said Dupee, who has been in practice for more than 30 years and teaches at Tufts University School of Medicine.
The state also faces a shortage of primary care doctors, Dupee said, making it harder for the newly insured to get an appointment. He said the bulk of his students are heading into subspecialties, with few choosing primary care.
Just half of primary care doctors were taking new patients last year, and average times for new patients seeking appointments with the doctors remained long — 45 days, up from 36 days the year before, a Massachusetts Medical Society survey found.
"If you are going to insure everyone, you have to make sure that you have doctors to care for those people," Dupee added.
Another struggle for Massachusetts has been its attempts to curb the costs of the law, said Lora Pellegrini, president of the Massachusetts Association of Health Plans. She faulted lawmakers for mandating that insurers cover more procedures and medicine, including hearing aids, oral cancer drugs and an assessment to help pay for the state's childhood vaccine program.
"To ultimately be sustainable, we have to address the costs," she said.
The state has worked to do so. In August, Gov. Deval Patrick signed a bill intended to save Massachusetts up to $200 billion over 15 years by encouraging a system that rewards doctors and hospitals for keeping patients healthy rather than paying piecemeal for every operation or treatment.
Employers must also brace for changes. In Massachusetts, businesses with 11 or more full-time workers were required make a "fair and reasonable" contribution to their workers' health insurance or pay a fee.
At family-owned Needham Electric Supply, five more employees began getting insurance when the law passed, said Vicki Maderia, director of human resources.
The company had considered the workers part-time, but they were deemed full-time under the law. Maderia said the cost was minimal.
"It helped us be a little more marketable because of a lot of the part-time workers were looking for benefits, so it did help us on the recruiting side," she said.
One key to the success of any health care law is to connect with people in their neighborhoods or at home to explain the law and get them enrolled, said Brian Rosman, research director for the advocacy group Health Care for All.
For example, residents need to be made aware of the individual mandate, which requires virtually everyone be insured or pay a tax penalty. Massachusetts was the first state to impose the mandate, and the federal law also includes one.
About 170,000 people in the state said they were uninsured in 2010, but about two-thirds did not report enough in income and were exempt from the tax penalty.
Of the rest, there are plenty of reasons why someone might be penalized rather than have insurance, said Rosman.
Sometimes it might be due to the difficulty of reaching out to Spanish- and Portuguese-speaking populations. In other cases, he said, some people are simply philosophically opposed to being told by the government to get insurance.
The number of people assessed the penalty has fallen steadily since the law was passed, from 67,000 in 2007, the first year the mandate took effect, to 44,000 in 2010.
Gruber said the most challenging part of establishing Massachusetts' exchange was that the state was essentially starting from scratch. There was new software to be developed and critical decisions to make.
"We really were experimenting," he said. "Other states will have, in many ways, an easier time than we did."
Associated Press writer Rodrique Ngowi contributed to this report.