As the tremors of health reform grow more forceful every day, their epicenter can be hard to pinpoint. Every state has approached the law differently, from Maryland moving ahead on a health exchange in March 2010 to numerous states refusing any role in implementation. Can a single state serve as an indicator for ACA success?

Kentucky makes a strong case. Colorado has both a highly competitive market and a healthy population, not something most states can claim. It would be tempting to pick Arkansas, but uncertainty saddles its private option, which will place the Medicaid expansion population into subsidized health exchange plans. But many Kentucky lawmakers, including Gov. Steve Beshear, have embraced the ACA as a once-in-a-lifetime chance to improve health in one of the nation's least healthy states.

As many states battled over health exchange control and Medicaid expansion, Kentucky quietly adopted both pieces. Now the state is pushing hard to have its exchange, Kynect, become the first certified by the U.S. Department of Health and Human Services.

Five carriers will sell policies through Kynect: Humana, Anthem, United Healthcare, Bluegrass Family Health and the Kentucky Health Cooperative. While that seems modest, Kentucky's commercial market has been a two-horse race between Louisville-based Humana and Anthem Blue Cross and Blue Shield of Kentucky. The number of new lives entering the system should benefit all plans. Anthem and the Cooperative will be the only statewide individual options, so they should receive greater enrollment. Given the incentives, business will likely be brisk. Kentucky estimates that 85 percent of its 332,000 exchange-eligible uninsured residents will qualify for some level of assistance.

Think of all the states that passed on exchange control and Medicaid expansion  many bearing striking resemblance to Kentucky. Its health status looks similar to the rest of the Southeast. In the UnitedHealth Foundation's 2012 Health Rankings, Kentucky was 44th overall, 50th for smoking, 41st for diabetes and 40th for obesity, numbers no state could brag about.

As for Medicaid expansion, Kentucky's past missteps appear fortuitous. A rocky statewide expansion of managed Medicaid in 2012 sent medical loss ratios soaring , leading Centene's Kentucky Spirit Health Plan to depart the program early. The state increased reimbursement rates and the managed Medicaid environment settled down, so the 2014 Medicaid expansion enrollment should proceed smoothly.

If health reform bends the cost and health curve, Kentucky could be the envy of neighboring states, most of which continue to oppose everything ACA. Years will pass before ACA impact can be quantified, but Kentucky seems uniquely suited to measure its progress.

Follow Bill Melville on Twitter @BillMelvilleHLI


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