Massachusetts is starting the most ambitious state effort yet to secure health insurance for all residents. It requires everyone to get health insurance if affordable coverage is available, either through their jobs or individually. People earning modest incomes can buy subsidized plans, but people with an income more than three times the poverty level, $61,956 for a family of four, must buy policies at market rate. While 127,000 residents, many of them previously uninsured, have bought the subsidized insurance, market-rate insurance is still costly.

Insurance reform proposals by most of the major presidential candidates count on the private individual market to expand coverage. Several candidates propose tax incentives for people to buy individual insurance. Consumers Union, the nonprofit publisher of Consumer Reports, opposes that approach to insurance reform because it does nothing to fix underlying problems, such as medical underwriting, and the tax breaks wouldn’t be enough to make insurance affordable for people with lower incomes.

Other candidates propose to expand coverage by bringing more people into the risk pool. Techniques include requiring everyone to have health insurance, allowing individuals to buy into large public or private risk pools, requiring insurers to cover everyone regardless of health history, and subsidizing premiums for lower-income consumers. Consumers Union believes that those are more promising approaches to insurance reform, so long as they are coupled with vigorous efforts to control costs, eliminate waste, and encourage better coordination of care for chronic conditions.