BOSTON -- When Massachusetts mandated health insurance three years ago, state leaders did so with the understanding that the top priority was near-universal coverage. And with 2.6 percent of resident uninsured, it has succeeded in achieving what is by far the lowest rate of uninsured in the country.

Figuring out how to pay for reform now and in the coming years remains much trickier.

“Cost, all along, most people have understood is the No. 1 challenge. And we're wrestling with that,” said Jon Kingsdale, executive director of the Commonwealth Health Insurance Connector Authority.

With an estimated 430,000 newly insured residents flooding an already crowded medical landscape, Massachusetts has the longest wait times to get a doctor’s appointment in the country – 50 days on average.

Reform is also proving to be more expensive than expected -- some estimates climb as high as $1.3 billion in 2009, though state officials tell NewsCenter 5 the true cost this year will be closer to $800 million.

“There will be, overall, more spending,” he said. “But it doesn't have to be much more spending, because the way they're getting care now is the most inefficient way. Overall the costs have not gone down, but they haven't ballooned out of control.”

Kingsdale points to some bright spots. In the fiscal year just started July 1, premiums will drop 2 percent for those who buy insurance through the state. Co-pays will stay the same as last year. The quasi-public Connector is also trimming administrative costs, using that money to increase the number of insured by 6 percent.

“But with this recession we could see demand going well above that, and that's where the issues are going to be,” Kingsdale said. “Can we accommodate that unconstrained growth or do we have to put some limits on it?”

And what about talk three years ago at health reform’s inception that it would save the state’s entire health care system money? To date, that has not come to fruition.

“No, it hasn't. I wouldn't try to convince you or your viewers that it has. If you give more people access to medical care, they will use more of it,” Kingsdale said.

Kingsdale said he believes that a recent analysis by the Massachusetts Taxpayers Association, which determined that health care reform has cost the state an extra $88 million per year since 2006, is accurate.

There have been unforeseen impacts of reform, too. A funding change called for in the state law has threatened the financial footing of so-called safety net hospitals like Boston Medical Center, by changing the way those centers are compensated for taking care of the poor and uninsured.

Tax penalties for those who refused to buy insurance after 2006 also have not brought in nearly the amount of revenue anticipated.

“I think he's admitted that this might not have been the proposal, exactly, he would have crafted, and yet the level of public support is really undiminished,” said Kingsdale.