Into this chasm stepped the hero of our story, Governor Mitt Romney, and his plan for health-care reform in Massachusetts. He realized that the solution to this problem was to ensure broad participation insurance markets by both the healthy and the sick. So he imposed an individual mandate, a requirement on Massachusetts residents to purchase insurance coverage. But he also realized that it would be both inhumane and impolitic to mandate that individuals purchase insurance they could not afford. For this reason he also provided for subsidies for individuals living below three times the federal poverty line to make insurance affordable. This “three-legged stool”—banning discrimination in insurance markets, mandating that individuals purchase insurance, and providing low-income subsidies for insurance purchase—became the basis for both our reform in Massachusetts and for the Affordable Care Act (ACA).

The enormous success of health-care reform in the almost six years since its passage in Massachusetts can make us more confident that this three-legged stool will work for the nation as a whole. We have covered about two-thirds of uninsured Massachusetts residents, and have lowered the premiums in the non-group market by half relative to national premium trends. And we have done so with broad public support. Moreover, this reform succeeded without interfering with the employer-sponsored insurance market that works for most of our residents: employer-sponsored insurance coverage has actually risen in Massachusetts, while falling sharply nationally, and the premiums for employer-sponsored insurance rose no faster in Massachusetts than they did nationally.

This was all possible because the individual mandate ended the “death spiral” of trying to obtain fairly priced insurance by just forcing insurers to charge everyone the same price. The bottom line is that we can’t have fairly priced insurance for the healthy and sick alike without the broad participation that is guaranteed by the mandate. The mandate is the spinach we have to eat to get the dessert that is fairly priced insurance coverage.