Abstract One of the most important developments in health policy in recent years was the health reform plan enacted by Massachusetts in April 2006. This sweeping bill reformed insurance markets, subsidized insurance coverage for a large swath of the population, introduced a new purchasing mechanism (the “Connector"), and mandated insurance coverage for almost all citizens. In this article, I review the history of health reform in Massachusetts, highlighting the unique features that came together to make reform a reality in this state. I then turn to a discussion of the major issues that have been faced in the first year of implementing this reform and the compromises made to maintain a broad consensus of support in the state. I also discuss the lessons learned and contrast the Massachusetts approach with alternatives, most notably plans that rely more strongly on the employer-based insurance system to expand insurance coverage in the United States.