I live in Boston too, and I have to say the system does seem pretty good for American citizens and foreigners who are permanent residents; but it's not so hot for foreign families on student visas who are poor by US standards. Schools give health insurance to the student and offer the option of buying very expensive health insurance for the rest of the family, other private health insurance companies won't take the rest of the family without the student signing up as well but the student's school doesn't usually let him or her opt-out of the school's insurance, the goverment run health insurance programs don't take the family because being here for 5 years on a student visa makes them "visitors" and thus ineligible. One affordable but risky option for a healthy family seems to be to not have health insurance and pay for all medical care directly, plus pay the fine for not having the mandatory health insurance --it is a small fraction of the cost of the health insurance.

Why doesn't the rest of the US use Boston's approach?

Massachusetts, not Boston. The way the US is setup each state is different - if you want that kind of health care, you move to Massachusetts. If you want fierce independence there are states that do that, there are states that heavily promote gun ownership, and those that discourage it. Some places have high income taxes, some property taxes, some no taxes, etc.

You can pick where you want to live based on what you like. A state in the US is almost as big as many countries, so you can think of the US as a conglomerate of many countries.

However Massachusetts is having some adverse selection going on as people who otherwise could not afford health care are going there and putting a drain on the system. They are also having a shortage of family doctors.

What is making the states very upset at the current federal plan is that they loose the opportunity to decide for themself how they want the state to run.

Thanks for the clarification. From the outside (I'm from the Netherlands) it is easy to forget the US is made up of many states which still have at least some sort of independence.

Same goes for Europe and its member states I guess.