On April 12, 2006, in the same space in Boston’s Faneuil Hall where colonists rallied for liberty, Beacon Hill’s big players lined up on stage under the sweeping oil painting of Daniel Webster.
They were there, with colonial-inspired drummers and a soundtrack of “Yankee Doodle” to mark a watershed moment: the signing of a law making Massachusetts the first state in the country to require that its residents have health insurance or pay a tax penalty.
If the emblems all around didn’t make the point, the stage was flanked with a pair of banners that said it plainly — “Making History In Healthcare.”
It would indeed prove to be a historic moment, as the Massachusetts model would later offer a blueprint for federal health care reform.
The law here came to be known as Romneycare, after the Republican governor whose signature made it official. But from the stage, then-Gov. Mitt Romney described it as a team effort, an “uncharacteristic” collaboration across ideologies and groups united by the promise of near-universal health coverage.
One of the collaborators was U.S. Sen. Ted Kennedy, who had been pushing for decades to expand health care access at the federal level.
“At long last the impossible dream of health care for all will finally become a reality in our commonwealth, and quality care will truly be available and affordable for each and every man, woman and child in our state,” Kennedy said at the bill signing.
Two decades later, state leaders past and present plan to return to Faneuil Hall Monday to celebrate the law’s anniversary — and the fact that Massachusetts, which lead the way all those years ago, still boasts the highest rate of health insurance coverage in the nation, at more than 97%.
More than 400,000 people who hadn’t previously had health insurance got covered after Romneycare — officially, Chapter 58 of the Acts of 2006 — was implemented. The law also created the first state-based insurance marketplace, the Massachusetts Health Connector, where people can shop for subsidized plans.
But while policymakers celebrate the accomplishment of widespread coverage, they continue to wrestle with that impossible dream of health care that’s widely accessible and affordable.
Amy Blackburn, interim executive director of the Massachusetts advocacy group Health Care for All, says the 2006 law echoed across the country, showing that the idea was politically feasible.
“It’s meaningful that two decades later, we have sustained that level of coverage, and I think that also speaks to how important it is in the grand scheme of health policy reform,” Blackburn said. “But what we also know after two decades of expanding this coverage is that having a health insurance card doesn’t actually mean you can afford the care you need when you need it.”
Forty percent of Massachusetts residents reported issues paying for health care in 2025, and health care expenses grew faster than wages and salaries from 2022 to 2024, according to the state’s Center for Health Information and Analysis.
Massachusetts has the highest family health insurance premiums of any state in the country, and more than one in eight residents are in debt from medical bills.
Blackburn said Health Care for All’s help line gets daily calls from people who are worried about costs or can’t even get in to see a primary care doctor.
Costs aren’t just a patient problem. Beacon Hill budget writers are trying to get a handle on unsustainable spending growth at MassHealth, the state’s Medicaid program.
Small businesses also say they’re struggling to keep up with providing coverage. Jon Hurst, president of the Retailers Association of Massachusetts, told lawmakers last week that his members, in a March survey, reported an average annual premium increase of nearly 14%.
Hurst has led the association since 1990. He says Beacon Hill hasn’t delivered on promises he heard in 2006, including that small businesses would be protected, to some degree, from the steep costs of providing insurance.
As Hurst sees it, a true cost-control effort from state government would either let consumers pick what level of health coverage they want — such as whether they want brand-name drugs over generic, or emergency only coverage instead of comprehensive — or implement strict pricing rules for hospitals and drug companies.
“Until we do one or the other, either put in real regulation or real consumer choice, and give them the marketplace power of choosing what they really need, what they want, and what they can afford, we’re going to continue to have this unaffordable medical inflation that hits premium payers and taxpayers alike,” Hurst said.
Hurst and Blackburn both serve on a working group that Gov. Maura Healey convened in January to find ways to make health care more affordable. Another state task force is looking specifically at primary care, in hopes of improving both cost and access.
While those broad reviews unfold, Beacon Hill has taken bites at pieces of the problem. A 2025 state law limits out-of-pocket costs for certain drugs that treat conditions like asthma and diabetes, and Healey moved to cut red tape by limiting the instances where patients need an insurer’s pre-approval for care.
One constant in passing far-reaching health care reforms, in 2006 or 2026, is the challenge of balancing the competing interests of so many players – patients, employers, insurance companies, hospitals, drug companies, doctors, unions and more.
To really make a dent in affordability, Blackburn said, all parties need to come to the table. She’s optimistic that’s happening now in Massachusetts, with Healey’s working group adding a sense of urgency.
“I think we can go back to the lessons that we learned in Chapter 58 around shared responsibility,” she said. “I think in order to really move the needle, everyone has to give a little.”
Jeffrey Sánchez was a state rep from Jamaica Plain when the 2006 health reform passed. He was one of the 155 out of 160 House votes in favor of the measure.
Sánchez, who now runs a legislative consulting firm in Boston, considers the law to be “the largest health equity initiative in the country, in terms of getting everybody under an umbrella to get the insurance card in their hand.”
He remembers then-Speaker Sal DiMasi using a nautical reference: everybody was on the boat, together.
“The seas are gonna be choppy, and there will be storms and so on and so forth, but we have to get through this,” Sánchez recalled. “And a part of the storm was always going to be cost.”
Today, with federal funding cuts and policy changes that threaten to erode the coverage gains under Romneycare, “We’re gonna have to get back on Sal’s boat,” Sánchez said.
On the 20th anniversary of the law signed amid pageantry at Faneuil Hall, Sánchez keeps the metaphor going with another emblem of Massachusetts history. He invoked the image of everyone standing on a dock, watching storm clouds gather, and trying to figure out how to rebuild the ship — like the restorations of the U.S.S. Constitution.
“We need to be like the Constitution,” Sánchez said. “We’re going to take a whole bunch of blasts to the side, and we’re going to wobble back and make it back to the dock and come together.”
