The 2006 Massachusetts health reform law increased insurance coverage and improved access to care for residents, in part due to the laws individual mandate. An individual mandate is also a component of the federal Patient Protection and Affordable Care Act (ACA), though its design differs from Massachusetts' mandate in many ways. The implementation of the federal mandate in 2014 raises complex questions about the interaction of the two requirements. We analyze three basic policy options available to the state, assessing their implications for residents and each policy option's ability to satisfy core policy objectives.