In 2006, Massachusetts signed a landmark health care reform bill aiming to make it the first US state to achieve universal health care coverage. A second bill followed in 2008 that sought to curb rising health care costs and improve quality of care. Key elements of the reforms included the creation of two new insurance programs: Commonwealth Care, offering subsidized coverage via private health plans to lowincome individuals; and Commonwealth Choice, offering unsubsidized private coverage to individuals and small businesses. A new independent state agency known as the Commonwealth Connector Authority was developed to oversee both insurance programs. Employers with 11 or more employees were required to offer to pay a “fair and reasonable” portion of their workers' health insurance premiums, or pay a per employee fee. Among the most controversial aspects of the reform was the introduction of an individual insurance mandate, requiring all adults to obtain health insurance or pay a fine via their state income taxes. Some aspects of these reforms, including a major role for the private sector and emphasis on performance measurement, embody principles of the governance and New Managerialism or New Public Management (NPM) theories that have gained popularity in recent decades. With regard to results of the reform, by 2009, more than 97% of Massachusetts residents were believed to have health insurance, the highest proportion of insured individuals in any US state. Although still in its early stages, the Massachusetts plan was commonly cited as a possible starting point for broader, national health care reform efforts.