BOSTON -- With the mandate that everyone in Massachusetts have health insurance taking effect today, more than 130,000 people - about a third of those who were uninsured a year ago - now have coverage, officials say.
But most of those who have signed up are poor enough to qualify for free or state-subsidized insurance.
People who must pay the full cost themselves - and who are crucial to the success of the plan - might now be a majority of the state's uninsured; not all are rushing to get coverage. Many of them are healthy young people in their 20s and 30s, state officials say.
Other hurdles include that some businesses, especially small ones, are struggling with the requirement that employers with more than 10 workers offer insurance.
People have until Dec. 31 to obtain coverage. After that, they will face a state penalty in the form of a lost tax exemption.
Observers of the state's progress since the health care law was passed in April 2006 say they are impressed that the varied constituencies - including health insurers, businesses, advocates, medical providers and taxpayers - largely continue to support the law and have worked to resolve differences. They say, and officials acknowledge, that there is still a long way to go.
"I would give it a B-plus," said John McDonough, executive director of Health Care for All, an advocacy group.
Massachusetts' model might not work everywhere. When the law passed, the state's 370,000 to 500,000 uninsured represented less than 10 percent of its population, a smaller proportion than in many states.
Massachusetts is deliberately taking things slowly. In 2008, the penalty for those not insured will be a loss of state tax exemption, worth about $219; later the penalty will be up to half of a monthly insurance premium for each month a person is uninsured.
Linda Impemba, 58, a marketing company employee in Wakefield, said she would remain uninsured and pay penalties and, as soon as her ailing mother dies, will leave Massachusetts. "There's no way in heaven I can possibly survive in this state," Impemba said.
"Now not only is my cost going to go up; everything's going to be raised so I can pay for the other people" to be insured.