Michael Manghan, of Fall River, a certified personal trainer and bartender — like many healthy young men — was uninsured. Now he has coverage under Commonwealth Care.

The Providence Journal / Frieda Squires

DARTMOUTH, MASS. — Mike Manghan has the lean, buffed frame of an athlete. He works out, plays sports, watches his diet and has never had an illness so serious that he landed in a hospital.

Until two months ago, the personal trainer and part-time bartender had never had health insurance. Manghan, who earns between $20,000 and $30,000 a year, says he didn’t have coverage because he couldn’t afford it; he didn’t work enough hours for a single employer to qualify for employer-sponsored health care.

Manghan, 39, finally has health care, thanks to Massachusetts’ path-breaking new program that requires all state residents to be covered by a health policy.

“I was lucky for years that nothing ever happened, except for the occasional sports injury — an ankle sprain or a sore shoulder,” said Manghan, of Fall River. “That was fine in my 20s, but when I got into my 30s and things started taking longer to heal, getting insurance was in the back of my mind, something I was thinking about.”

Last spring, while watching New England Sports Network, the cable channel that carries the Boston Red Sox, Manghan found out about Commonwealth Care, a plan that provides comprehensive health coverage to people without access to work-based insurance who earn less than 300 percent of the federal poverty level — or about $31,000 for someone like Manghan.

“My girlfriend told me I should look into it,” said Manghan, as he nibbled on steak tips one afternoon last week at a restaurant near the gym where he trains clients. “I jumped on the Web site and I printed out an application. I filled it out and that was it — it was really easy.”

Manghan is one of nearly 200,000 of Massachusetts’ more than 6.4 million residents who were uninsured and have signed up for coverage under the state’s ambitious plan — the first time any state has aimed to insure 100 percent of its population.

He fits the model of the largest segment of uninsured state residents — a man in his 20s or 30s. This group is what Governor Patrick, in a recent speech at Brown University, called the “young masters of the universe” — people who are not sick and “think they are going to live forever.”

To reach this group, Commonwealth Care has aggressively signed up state residents to new health insurance policies under a plan that has been so successful so far that the state is now worried about how much it will cost taxpayers to subsidize the effort at a time when the New England economy is flat and the state is short of money. One early projection shows the costs to the state could be $157 million higher than originally thought.

In Rhode Island, Democratic Lt. Gov. Elizabeth Roberts has gathered a group of health experts and representatives of business, organized labor, hospitals, insurance companies and political figures to determine whether elements of the Massachusetts plan could be successfully adopted by Rhode Island, where about 10 percent of residents are uninsured.

Under the plan approved last year, Massachusetts decided to deal with the problem of access — getting as many uninsured residents covered as possible — before tackling the thorny issue of how to control medical costs.

The state set up a carrot-and-stick approach to force people to get insurance. Everyone is required to get health insurance in much the same way as all motorists must obtain auto insurance. Those who refuse to get coverage by Dec. 31 face a fine of $219 plus the loss of their personal exemption when they file their state income taxes. The penalties increase steeply next year.

Employers must offer coverage to their employees. Companies that employ 11 or more and fail to offer insurance face a fine of $295 per employee, a figure sure to escalate in future years, say those familiar with the program. So far, very few employers have decided not to cover workers and pay the fine. Companies must offer insurance that workers can finance with before-tax dollars.

People who cannot afford insurance are eligible for an array of taxpayer-subsidized plans, depending on their income. The very poor qualify for the state’s version of Medicaid, the joint federal-state program that provides health care to the poor. Elderly Massachusetts residents are covered by Medicare, as they are throughout the United States.

About 60 percent of the state’s residents get their health care through work-based health insurance, the way most Americans have received insurance since World War II, when employers began covering their workers’ health care as a way to reward employees during a time when wage controls barred salary raises.

At the start of the Massachusetts effort, there were wildly differing estimates of just how many residents lacked coverage, says John E. McDonough, executive director of Health Care for All, a consumer group instrumental in forging the new plan.

A state survey pegged the number at about 375,000. U.S. Census Bureau estimates put the number at between 625,000 and 675,000. And a survey by the Urban Institute, a think-tank, estimated that between 530,000 and 570,000 lacked coverage, a figure McDonough says will probably turn out to be the most accurate.

The profile of the average uninsured Massachusetts resident is a 37-year-old man, says Richard Powers, spokesman for Commonwealth Care.

Many of them are outwardly healthy. They fall into a category known among health planners as “young invincibles,” people who believe they won’t get sick and don’t need insurance.

To reach this group, Commonwealth Care has been aggressively courting them. Besides much use of the Internet, the state has also advertised extensively during the televised sports — Red Sox baseball, Celtics basketball and Bruins hockey — this group watches.

“The program is working well, which is not to say it is working perfectly,” says McDonough, the health consumer advocate.

The program was the product of an elaborate political compromise among people and interests who often don’t get along — liberal Democrats, conservative Republicans, business and organized labor, insurers and hospitals. Especially helpful to launching the program was the work of Massachusetts Democratic Sen. Edward Kennedy, the Senate’s liberal lion and an advocate of universal health care during his entire 44-year career, and former Republican Gov. Mitt Romney, who is now running for the GOP presidential nomination.

Liberal priorities, such as quality universal coverage of all citizens, regardless of income, were blended with the conservative idea that citizens had personal responsibility for their own health. And it was done without establishing a new bureaucracy to take over all aspects of paying for health care, such as a so-called “single-payer” system long pushed by liberals.

Instead, the state’s private health insurance companies keep their traditional role of insuring most residents, along with such government programs as Medicare and Medicaid.

So many people have signed up for the various insurance plans that for the program to work properly, say experts of all stripes, focus must shift to controlling costs, trying to reverse a trend in which spending has increased every year faster than the national inflation rate of about 3 percent.

“It is a good plan, but in the long run the question is going to be: How do you pay for it?” says Anya Rader Wallack, a health-care policy consultant.

Massachusetts “made a conscious effort to go after access for all before dealing with the cost issue,” says Michael Doonan, executive director of the Massachusetts Health Advisory Forum at Brandeis University. Doonan says that makes sense because some needed changes in the system work best when everyone has coverage.

An example Doonan and Stuart Altman, another Brandeis University health policy expert, point to is the need to wean people with minor medical problems off using hospital emergency rooms and into much lower-cost venues, such as doctors’ offices and clinics.

“Emergency rooms have become the new health clinics for the lower and middle classes,” says Altman. “That is a behavior that has to be changed in order to address costs. You shouldn’t be going there for a sore throat.”

The theory is that with everyone covered, insurers can erect serious financial penalties — such as very high copayments for those who use emergency rooms for minor problems — that will steer patients into lower-cost alternatives.

Another area that needs emphasis, says Doonan, is controlling chronic diseases, such as diabetes, congestive heart disease and asthma, so that patients principally get their care at clinics and doctors’ offices, avoiding expensive hospital stays.

And there are the obvious lifestyle changes that doctors constantly drum into people, such as losing weight and quitting cigarette smoking, moves that would reduce treatment costs over the long run.

The tougher decisions, says Altman, involve the way death has become medicalized in the United States. Options to expensive treatments “near the end of life that aren’t very effective” need to be pursued, including increased hospice care.

The Massachusetts business community has been supporting the plan, according to a recent survey by the National Opinion Center at the University of Chicago. The survey of 1,056 randomly selected businesses showed that 55 percent favored extending the law to all firms, not just those with 11 employees or more.

While businesses generally support the law, those attitudes could change if costs jump, says Jon Hurst, president of the Retail Association of Massachusetts, which represents 3,000 small businesses with an average of 10 employees each.

“The long-term viability of the law is in question if the costs are not addressed,” said Hurst. Large employers, Hurst says, have the ability to negotiate lower rates than small business, so insurers must be more open about their rates.

One major worry of small-business leaders, says Hurst, is the transfer of money to the health-care insurance and medical care community.

“You’ve got money going from small businesses in premiums to the large insurers and doctors and hospitals,” said Hurst. “It is a transfer of wealth.”

Hurst says more low-cost clinics, such as the CVS drugstore chain’s Minute Clinic medical offices, would help lower costs.

Most businesses are participating, paying at least one-third of employee coverage, rather than paying the $295 fine per employee for not offering coverage, says Bill Virdon, state director of the National Federation of Independent Business, which represents 9,000 small businesses in Massachusetts.

Just 500 of the state’s 62,000 firms surveyed have indicated they will pay the fine, rather than provide employee insurance.

“If you pay the $295 fee, you are not getting anything,” says Virdon. “Most businesses will go along with this plan.” Stabilizing costs will not be easy, given the economics of medical care in the United States, particularly in high-cost Massachusetts, Altman says. “In the U.S., medicine is big business, compared to Canada and some European countries, where it is seen as a social service.

“Everyone in the mix in medical care in the U.S. — the doctors, hospital administrators, the insurance executives, even the nurses — is paid comparatively well,” said Altman.

As for Manghan, the Fall River personal trainer, he has seen a doctor for the first time in years, had a general physical and a full run of blood tests.

“I went to my primary care doctor and I found out I’m doing well,” said Manghan. “But my brother recently got diagnosed with diabetes, so now that I know it is in the family, I’m going to keep having my checkups.”

smackay@projo.com