in massachusetts: has health reform made a difference?", compared bankruptcy filers from 2007, before reforms were implemented, to those filing in the post-reform 2009 environment to see what role medical costs played. the study found that: 1) from 2007 to 2009, the total number of medical bankruptcies (defined as due to unpaid medical bills or to loss of income due to illness, with no distinction between those causes) in massachusetts increased by more than one third, from 7,504 to 10,093; and 2) illness and medical costs contributed to 59.3% of bankruptcies in 2007 and 52.9% in 2009. the researchers note that the financial crisis beginning in 2008 likely contributed to the increased number of bankruptcies, and massachusetts' increase in medical bankruptcies over the 2007–2009 period was nevertheless below the national average rate of increase. still, the researchers explain that health costs continued to go up over the period in question, and their overall findings are "incompatible with claims that health reform has cut medical bankruptcy filings significantly." a 2015 study found that the law had "modest effects" on costs of outpatient care for people who were already insured. according to a 2016 study in the american economic journal, the reform "reduced the amount of debt that was past due, improved credit scores, reduced personal bankruptcies and reduced third-party collections." the authors note that the "results show that health care reform has implications that extend well beyond the health of those who gain insurance coverage." in 2010, the boston globe reported that more than a thousand people in massachusetts had "gamed" the mandate/penalty provision of the law since implementation by choosing to be insured only a few months a year, typically when in need of a specific medical procedure. on the average, the globe reported, these part-time enrollees were paying $1,200–$1,600 in premiums over a few months and receiving $10,000 or more in healthcare services before again dropping coverage. a study conducted by the urban institute and released in december 2010 by the massachusetts division of health care finance and policy stated that as of june 2010, 98.1 percent of state residents had coverage. this compared to 97.3 percent having coverage in the state in 2009 and 83.3 percent having coverage nationwide. among children and seniors the 2010 coverage rate was even higher, at 99.8 percent and 99.6 percent respectively. the breakdown of insurance coverage consisted of that 65.1 percent of state residents being covered by employers, 16.4 percent by medicare, and 16.6 percent via public plans such as commonwealth care. the state's secretary of health and human services, judyann bigby, said, "massachusetts' achievements in health care reform have been nothing short of extraordinary. with employers, government and individuals all sharing the responsibility of reform, we continue to have the highest insurance rate in the nation." in june 2011, a boston globe review concluded that the healthcare overhaul "has, after five years, worked as well as or better than expected." a study by the fiscally conservative beacon hill institute was of the view that the reform was "responsible for a dramatic increase in health care spending," however. in 2012, the blue cross foundation of massachusetts funded and released research that showed that the 2006 law and its subsequent amendments – simply in terms of measuring the state-budget effect on the uncompensated care pool and funding subsidized insurance had cost approximately $2 billion in fiscal year 2011 versus approximately $1 billion in fiscal year 2006. some of this doubling in cost was funded by temporary grants and waivers from the united states federal government. the blue cross funded research did not address the increased costs in premiums for employers and individuals or other market dynamics – such as increased providers' costs and increased co-pays/deductibles – necessary to meet minimum creditable coverage standards that were introduced in massachusetts by other parts of the 2006 legislature and its resulting regulations. separate research on premiums and expenditures found that fully adjusted premiums per member per month (ppmpm) for massachusetts residents covered by comprehensive private insurance policies (approximately two thirds of the state population) increased approximately 9% in both 2009 and 2010 for subscribers in the "merged market", 7% in the midsized group market, and 5.4% in the large group market. these premium increase do not reflect actual resident experience particularly in the merged market because massachusetts regulations allow age and other rating factors (e.g., even if premiums were held flat for 55-year-olds living on cape cod in construction work from year to year, the 55-year-old in 2009 would pay 10% more in 2010 for the same policy, possibly with lesser benefits). during the years before the changes in the state law related to the enactment of the federal ppaca, the state still used the free care pool—renamed the health safety net—both as originally intended and to fund the subsidies for free (under 150% of fpl) and almost free (151–300% of fpl) networked health care insurance. in addition the state spent a substantial amount of general revenue on the insurance reform. based on the combination of the increased health safety net tax, general revenue (state income and sales taxes were increased 20%) and smaller additional taxes, the cost of the reform reached about 2% of the state's annual budget in fiscal year 2013, which ended june 30, 2013, up from 1.5% in fiscal 2011. data following enactment of mandatory insurance showed total emergency visits and spending continued to increase, and low-severity emergency visits decreased less than 2%; researchers concluded, "to the extent that policymakers expected a substantial decrease in overall and low-severity ed visits, this study does not support those expectations." other analysis concluded that preventable ed visits were reduced 5-8% for non-urgent or primary care ed visits relative to other states. a more complete report released in january 2012 found between 2006 and 2010 emergency department visits and non-urgent visits had dropped 1.9 and 3.8% respectively. a 2014 study found that the law was associated with "a small but consistent increase" in ed use in the state. a 2014 study found that the reform was associated with "significant reductions in all-cause mortality and deaths from causes amenable to health care." transition to aca at the point of the implementation of ppaca in 2014, of those citizens acquiring insurance through pre-aca massachusetts health connector plans, approximately 100,000 massachusetts residents who received free or highly subsidized commonwealth care insurance, were expected be needed to be moved to medicaid. the number of available plans under the affordable care act that will offer service beginning on january 1, 2014, rose to more than 100 from just under 100 in 2013. the open enrollment period of the insurance marketplace, during which citizens may re-enroll or purchase, lasted from 1 october 2013 to 31 march 2014, but those who did not re-enroll by december 15, were to have no insurance coverage in january 2014 (unless they were among the 100,000 moved to medicaid). at the start of the affordable care act open enrollment at the end of 2013, there was a major technical failure, and the ma health connector software did not work at all. to handle this problem, a special temporary medicaid was set up, and given to over 320,000 people at no immediate cost to them, who would have under normal aca procedures gotten either a traditional medicaid, an aca expanded medicaid, or an aca on-exchange plan. the ma health connector was functional starting at open enrollment for 2015, though problems were still widely reported. outcomes following transition to aca according to the kaiser family foundation, in 2019 the state's uninsured rate was about 3%, which at the time was the lowest in the country. though 22% still have trouble paying their medical bills, "with many complaining that high-deductible health plans come with steep out-of-pocket costs." in 2022, the following carriers offer plans through the massachusetts health connector insurance marketplace: allways health partners (formerly neighborhood health plan) blue cross blue shield of massachusetts (bcbsma) boston medical center/bmc healthnet plan (bmchp) fallon community health plan harvard pilgrim health care (hphc) health new england (hne) tufts (two separate entities: tufts hmo and tufts health public plan) unitedhealthcare fountas v. dormitzer a legal challenge was filed in the superior court of essex county, contesting the fine imposed for a citizen's failure to get health insurance as well as the fine imposed for a failure to provide information on a tax return as to whether that citizen had health insurance. the judge dismissed the case upon a motion filed by an assistant to attorney general martha coakley for failure to state a case upon which relief can be granted. a petition for a writ of mandamus to the massachusetts supreme judicial court (sjc), ordering essex superior court to vacate this dismissal on procedural grounds, the failure to provide trial by jury in a dispute over property as requested by the plaintiff, was denied by associate justice spina. an appeal was then filed with the massachusetts appeals court. a later petition for a writ of mandamus with the sjc was also denied, this time by chief justice ireland. the appeals court then heard the appeal and declined to send the case back to essex superior court for trial by jury based on their belief that no facts needed to be determined and therefore trial by jury in this case was not a protected right under either the us or massachusetts constitutions. the sjc declined to hear any further appeals. transition from fee-for-service to accountable care in november 2016, masshealth received a federal medicare waiver that allowed it to transition from fee-for-service payment to the use of accountable care organizations, expected to begin operation in december 2017. this expanded the similar one care prevention-oriented program for massachusetts patients who were enrolled in both medicare and medicaid, or had disabilities or very low income.