"Mandate wasn't even a consideration for me," said self-employed public relations representative Mary Flynn, who lives near Cape Cod and suffers from chronic asthma. "What was a consideration for me was that I was 61 years old. I needed health insurance."
After leaving her corporate job to start her own business, Flynn had lost her health insurance.
"I was totally scared. I didn't know what I was going to do," she said.
She found that her lower income made her eligible for a subsidized plan that now costs her nothing.
Still, insurance premiums in Massachusetts have increased from an average of $331 per month in 2006 to $401 per month in 2010.
In Massachusetts, there is not just an individual mandate to buy insurance, there is also an employer mandate to provide it, and employers do for 79 percent of Massachusetts residents, up ten percent since health reform was implemented, bucking the downward national trend, whereby only 60 percent of employers nationwide provide health insurance.
The penalties for individuals not enrolling in a plan range from $19 a month to a maximum $105, depending on income. People earning less than $16,345 a year are exempt from the mandate. The fine is no more than $58 per month for those earning up to $32,676 per year. Above that, refusal to enroll leads to the $105 bill.
Every year, the number of Massachusetts residents opting out of health insurance has shrunk from 67,000 in 2007 to 44,000 in 2010.
George Montilio, who runs a 65-year-old family wholesale and retail bakery business in Brockton, is among the employers opting out.
"If we had to put health insurance into our company -- that would totally make us unprofitable," Montilio said. "It's almost seven percent of my gross."
With 70 employees - 30 full-time and 40 part-time - he calculates that complying with the mandate would cost him $300,000 per year in premiums. Instead, he chooses to pay the state's annual fines per employee, which for him amount to almost $20,000 a year.
"We pay the penalty," Montilio said. "My choice."
Montilio says he would like to offer health benefits to retain good employees, but he believes raising prices to foot the insurance bill would alienate customers.
"Absolute mandate - that's just not right. We feel that, you know, we should be able to make our own decisions to run our business," he said.
Romney left the governor's office at the end of one term, only nine months after he signed health reform, so it's fallen to his successor, Democrat Deval Patrick, to implement the law for the past five years
"I was skeptical of it when I first heard about it," Patrick said. "But the basic insurance idea that you get everybody in and spread the risk widely so you keep the cost down for everybody -- very, very smart."
Yet since the reform, overall health spending has risen from as a piece of the state budget pie, from 36 percent in 2006 to 43 percent in 2011, and Massachusetts spends $9,278 per person per year on health care, more than any other state.
"We made a judgment about health being a public good, and that everybody ought to have access to affordable care," Patrick said. "What folks did was come together and decide that there were more than the usual two choices, which was between a perfect solution or no solution at all, and to try something."