The law essentially left in place the existing health insurance structure and rearranged money within the system. It required no serious cost-containment measures that would have assured the program’s future, but would have cut into the profits of the state’s powerful medical and insurance interests. Employers still cover their workers, insurance companies still sell policies that pay for care at the state’s high-end hospitals, and a federal infusion of cash allows the state to expand Medicaid coverage.

The law’s novel feature is its individual mandate—-the requirement that every resident must have health coverage either from a public program like Medicaid or from a policy sold by commercial insurers. If they don’t get coverage, they face a tax penalty, now about $1,000 a year. The state either fully or partially subsidizes premiums for individuals with annual incomes lower than about $32,500 and for families of four with incomes lower than about $66,000. For people who don’t qualify for government help, the state offers a shopping service called the Connector to make buying easier. Because of the mandate, some 97 percent of Massachusetts’s population now has health insurance.

Until recently, few have criticized the program. One health care provider who asked for anonymity told me: “Nobody wants to be quoted as going against Senator Kennedy. Nobody wants to be the one who says the emperor has no clothes. If you or your organization speaks out, you get cut off politically.” One state legislator who has spoken up is State Senator Jamie Eldridge. Earlier this year, Eldridge, who voted for the law, offered this candid assessment to a Congressional committee:

The assumption was that, as more people—and, in particular, more young and relatively healthy people—joined the system, premiums would go down across the board. There was also the assumption that as more people became insured, the number of people going to the emergency room would drop dramatically, saving the Commonwealth money. Neither of those things have happened—at least not enough to produce the cost savings we were told we would see. In fact, health care reform has cost the Commonwealth much more than expected—-up to a record $1.3 billion this year. It is maddening that so many of our public health care dollars are diverted to HMOs and health insurance companies, under the current employer-based Massachusetts health care system.

Politics inevitably led to the Blue Cross Blue Shield of Massachusetts Foundation, a philanthropic organization established in 2001 with a $55 million endowment from Blue Cross Blue Shield, the state’s dominant insurer, with the mission of expanding access to health care. The Foundation issued several reports intended to inform and influence the debate that lead to reform. Major funding for that initiative—called Roadmap to Coverage—came from Blue Cross Blue Shield of Massachusetts and Partners HealthCare (the big, influential health care system that includes Massachusetts General Hospital, the state’s huge teaching institution).

The Foundation has spread its money around to fund surveys gauging public opinion about the law and to help grassroots groups sign up residents for subsidized insurance. In January, it awarded $50,000 to Community Partners in Amherst to help with the group’s outreach efforts to enroll more people in public programs. It gave $50,000 to Health Care for All, the state’s premier health advocacy group, which has been a strong supporter of reform. In 2006, the year the law was passed, Health Care for All’s website disclosed that the Foundation, along with many of the state’s insurers and hospitals, each donated $10,000 or more to fund its advocacy activities. The group’s then-executive director, John McDonough, is now an aide to Senator Kennedy.

I sat down with Nancy Turnbull, who was president of the Foundation when the law was enacted and now teaches at the Harvard School of Public Health. The big winners, Turnbull told me (aside from those who now have subsidized coverage), “were the hospitals that got rate increases and lots of insured patients who didn’t have insurance before.”

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.