Massachusetts's 2006 universal health insurance reform expands Medicaid and uses new sliding-scale subsidies and purchasing mechanisms to make coverage more affordable for individuals and small businesses. Individuals must buy insurance, and employers must offer it or pay a small assessment. How feasible is this approach for the District of Columbia? DC has a relatively small uninsured population, generous publicly sponsored coverage, and an existing eligibility process to administer subsidies. But, its insurance market regulation and total safety net payments for uninsured care are low compared with Massachusetts, creating greater challenges if the District tries to replicate the Massachusetts model.