The No. 1 goal of the Affordable Care Act is to make sure that more Americans have health insurance.
How's that working out?
We learned recently that, nationally, the uninsured rate has dropped from a high of 18 percent in 2013 to 13.4 percent as of June, according to the Gallup-Healthways Well-Being Index.
And the same survey has numbers for Colorado: In 2013, 17 percent of residents had no insurance. A year later, after the start of the ACA, the number is down to 11 percent. Colorado ranks fifth among all states in reducing the size of its uninsured population.
Colorado's success didn't happen by accident, and it stands in stark contrast to states that have not pursued reforms, either on their own or though the ACA.
In Colorado, it took foresight and cooperation among lawmakers, policy-makers, administrators and other stakeholders. When the ACA came along in 2010, Colorado had already taken many important steps to reform health insurance and access to health care.
As it turns out, Colorado provides a good example for doing things the right way. Consider that nine years ago, in 2005:
• 785,000 people (more than 17 percent of Colorado's population) were without health insurance in any given month, and about 1.1 million residents were uninsured at sometime during the year.
• Adults without dependent children were not eligible for Medicaid, regardless of how low their annual income was.
• Adults and children with pre-existing conditions could be denied health insurance coverage, and even if they could get insurance, the cost was all too often out of reach.
• Colorado was a "file and use" state, which meant that an insurance company was not required to receive approval for increases in premiums before they were sent to the public.
• Women could be charged higher premiums for the same coverage as men (in some cases 50 percent more) because of gender alone. Many non-smoking women in Colorado had to pay significantly higher premiums than male smokers of the same age living in the same ZIP code.
But Colorado citizens and policy-makers were committed to improving this situation. In 2006, Colorado funded a blue-ribbon commission on health care reform to consider its options for improving the state's health care system.
In 2008, the state legislature passed a law requiring review and approval of proposed increases in insurance premiums. In its first year under the new process, Colorado rejected or reduced a higher percentage of proposed rate increases than any other state.
In 2009, Colorado hospitals, state policy-makers and the federal government worked to find funding for the state's largest expansion of Medicaid eligibility in history. In the same year, gender rating was eliminated - well in advance of the ACA.
After the ACA, bipartisan legislation was passed to create a state-based health insurance exchange, and in 2013 the governor and the state legislature approved the expansion of Medicaid in Colorado to all citizens with incomes under 133 percent of the federal poverty level.
The resulting scorecard shows that Colorado has reduced the number of its uninsured by 6 percentage points since 2013; low-income adults without children are now eligible for insurance coverage under Medicaid; 141,000 citizens have purchased coverage through the state-based health insurance exchange; women no longer pay higher premiums based solely on gender; and the median premium rate increase in Colorado for 2015 is 3.1 percent.
Not bad compared to nine years ago.
In terms of percentage of population uninsured, Colorado ranks 14th, at 11 percent. That contrasts with bottom-ranked Texas, Mississippi, Georgia, Florida and Louisiana, with rates of uninsured ranging from 24 percent to 18.4 percent.
In those states, governors and state legislatures strongly opposed the ACA. They did not expand Medicaid eligibility or set up their own state-based health insurance exchanges - and in many cases, they threw up roadblocks. According to the Gallup survey, in the 21 states that have expanded Medicaid and set up their own state based exchange the uninsured rate has dropped by 4 percent. In the remaining 29 states that implemented only one or none of these reforms, the drop in the uninsured population averaged 2.2 percent.
Where Colorado ranked in the top five for percentage-point drop in the rate of uninsured, a reduction of six points, some states saw increases or little change in their uninsured populations - Kansas (+5.1 points), Iowa (+0.6 point) and Missouri, Virginia and Utah, which remained relatively static. In three of these states where data is available (Kansas, Iowa and Virginia), median health insurance premiums for 2015 will increase from 10.2 to 11.5 percent.
Embracing the reforms of the ACA doesn't guarantee a better health-care system in a state. But opposing them doesn't seem to, either. It can even be argued that actively opposing the law produces a worse track record.
Many factors determine how well a health-care system works in any given state, ranging from the economic health of a state to a diverse and competitive insurance market to a robust health-care provider network. But what we have seen in states like Colorado is that an active and cooperative effort to improve access and affordability can deliver better outcomes. And in terms of the future, those states will have a stronger foundation to build on.