For the purposes of this post, I’m defining mandatory insurance coverage as 99% of the U.S.population with some form of public or private health insurance. As for the remaining 1%, there will always be a few conscientious objectors, especially in America.

So how do we do it? Mostly by following the example of Massachusetts, which has already achieved 98% coverage. So how does Massachusetts do it?

Massachusetts requires residents over 18 with access to affordable, comprehensive plans to maintain coverage, primarily through the state tax filing process. Specifically, the state imposes tax penalties on individuals lacking "Minimum Creditable Coverage" (MCC) for more than three consecutive months.For most plans, MCC standards include:

  • Coverage for a comprehensive set of services (e.g., doctors’ visits, hospital admissions, day surgery, emergency services, mental health and substance abuse, and prescription drug coverage)

  • Doctor visits for preventive care, without cost-sharing

  • A cap on annual deductibles

  • An annual maximum on out-of-pocket spending for plans with up-front deductibles or co-insurance on core services

Here is a list of plans that automatically meet MCC requirements:

  1. Medicare Part A or B

  2. Any ConnectorCare plan (state-subsidized coverage program)

  3. Any Health Connector plan (state's Marketplace for health and dental insurance).

  4. MassHealth (combined Medicaid and Children’s Health Insurance Program), except MassHealth Limited.

  5. A Catastrophic Health Plan

  6. A qualified Student Health Insurance Program (SHIP) offered by a Massachusetts college or university

  7. A tribal or Indian Health Service plan

  8. TRICARE (U.S. Department of Defense's health care program providing comprehensive medical and pharmacy benefits for uniformed service members, retirees, and their families)

  9. The U.S. Veterans Administration Health System

  10. Peace Corps, VISTA, or AmeriCorps or National Civilian Community Corps coverage

  11. Any health arrangement provided by established religious organizations comprised of individuals with sincerely held beliefs provided certain standards are met.

Catastrophic health plans are especially attractive to the young and healthy. Catastrophic plans in Massachusetts offer low premiums but very high deductibles, covering only major emergencies and 3 primary care visits per year. These plans are strictly for individuals under 30 or those with a specific financial hardship exemption. For 2026, the deductibles for all Catastrophic plans are $10,600 for an individual or $21,200 for a family. After that much is spent, the insurance company pays for all covered services, with no co-payment or co-insurance.  

According to the Commonwealth Beacon, a recent poll found that the people of Massachusetts are pretty happy with their system: 

“The vast majority of residents say they are either very satisfied (40 percent) or somewhat satisfied (36 percent) with their health insurance, with about the same sentiment for people whose care they manage.” 

But…

“Given an open-ended question about how they would describe the health care system in Massachusetts, responses generally reflected three things: it’s excellent, it’s pricey, and it’s slow…The state Health Policy Commission noted in 2024 that Massachusetts is the state with the second highest family health insurance premiums, including out of pocket spending, with the average annual cost of health care for a family exceeding $29,000.”

Ouch! I’m guessing that Massachusetts won’t reach universal coverage without figuring out a way to lower healthcare costs.

Next: How to reduce the cost of healthcare.

Note: In a separate poll, Gallup recently surveyed nearly 20,000 Americans nationwide on their healthcare experiences and ranked each state’s performance accordingly. In addition to overall rankings, states were evaluated separately on key dimensions of the healthcare experience — cost, quality and access. Massachusetts ranked first (ie, best performing) on cost, second on quality and tenth on access. That sounds good until you see the grades respondents gave for these same indicators. For example, Massachusetts residents gave their state a D+ on cost!

Sources:

How Do Americans Experience Healthcare in Their State? / Gallup  November 18, 2025

Massachusetts Individual Mandate Massachusetts Health Connector. Accessed February 10, 2026.  

New poll shows high satisfaction with health insurance in Mass., even as residents delay or skip care for cost reasons By Jennifer Smith | Commonwealth Beacon September 12, 2025