Tony Brooks needed health insurance by July 1. It's required by law.
He might even have qualified for subsidized care, but he's not sure. In the end, he didn't sign up.
"I don't know," he says. "I just gotta read more about it."
July 1 should have been another milestone in Massachusetts' journey to universal healthcare. It's a trailblazer policy that's being watched across the nation.
So it may seem discouraging that Mr. Brooks – and up to two-thirds of the state's uninsured – haven't signed up yet. If participation falters, especially among healthy adults, the predominance of residents with high medical costs could spur investors to raise premiums, and Massachusetts could see its healthcare expenses swell.
But officials and healthcare analysts aren't worried about meeting the deadline. They say the plan's success depends on whether people sign up in the coming months, or even years.
"It's a marathon, not a sprint," says Dick Powers, spokesman for the Commonwealth Health Insurance Connector Authority, a body established by the healthcare law to oversee its implementation.
Massachusetts passed the country's first law requiring adults to get health insurance in April, 2006. In the past 14 months, it has taken several steps toward covering its 372,000 uninsured residents (about 6 percent of its population):
• It expanded the state's Medicaid program last July to include 50,000 more adults and children.
• In October, it launched Commonwealth Care, a set of state-subsidized plans for low-income residents. Of the 80,000 enrolled so far, three-quarters get full subsidies.
• In May, it unveiled Commonwealth Choice, an unsubsidized program offering a menu of private insurance plans to help individuals compare and select.
Altogether, a majority of people eligible for subsidized care now have it. There is no reliable data on how many people have bought unsubsidized insurance since the law was passed. But analysts agree it's nowhere near 100 percent of those who were required to have it by Sunday.
Why aren't Massachusetts residents signing on? Many people are only vaguely aware of the law, experts say, and don't know much about it.
"They don't know what to do, even if they have a sense that they need to do something," says Mike DeChiara of Community Partners, a health-information organization in Amherst, Mass. "There are probably some people hanging back because ... with everything new, they're just waiting to figure it out."
To some, July 1 may have been just another quiet Sunday. There are people who don't watch the news, attend community events, or listen to rules, says Shirley Dorsey of Boston's Roxbury neighborhood. She can think of several friends and family members who could qualify for state-paid care but haven't gotten it – including her sister. So she gave three community volunteers her sister's phone number to prod her into action.
Individuals who are informed know they can afford to wait: Though July 1 was the deadline for coverage, a $219 penalty doesn't kick in until Dec. 31. Sunday was like a warning bell.
"It's the day the door opens, but it's not the day the door closes," says Jonathan Gruber, a board member at the connector authority and a health economist at the Massachusetts Institute of Technology in Cambridge, Mass.
Meeting the deadline doesn't determine the plan's success according to public officials and healthcare analysts. Just getting a majority of subsidized people into the system has benefited new enrollees and the state, some say.
About 70,000 people moved to Commonwealth Care from the "free care" policy, in which the state helps foot hospital bills directly. Now, the government will start contributing to their monthly premiums instead – and save a lot of money.
"You get subsidized people, and that takes pressure off the free-care pool," says Mr. Powers.
The key to keeping premiums low is to bring young, healthy adults on board, whether they're subsidized or not, explains Robert Blendon, a professor of health policy at the Harvard School of Public Health in Boston. They'll help offset costs because they seek less medical attention than others do.
They're also the largest demographic of the uninsured in Massachusetts. Bay State residents ages 18 to 34 are half as likely to have health insurance as any other age group, the Urban Institute reported in 2005. Some young adults resist paying into a healthcare pool because they're least likely to take from it. The connector authority hopes to persuade them that the security of having insurance is worth the cost. People buy auto insurance, the reasoning goes, and humans are much more valuable than cars.
Brooks, who hasn't had healthcare since quitting his city job in 2000 to open a small eatery in Cambridge, Mass., appreciates the analogy. But he says, "Things are still tight," he admits. "It's just hard to find a good plan."