BOSTON — 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.
The influx of 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.