The new report raises an important question: Will consumers experience health reform differently based on the decisions their states made?
Twenty-four states, by the Commonwealth Fund's count, have declined to expand Medicaid or remain undecided. Texas is one of them.
"We have 1 million people who are uninsured today who are too poor to get help through the marketplace and will have no access to affordable insurance," said Stacey Pogue, a senior policy analyst at the Center for Public Policy Priorities, an Austin-based advocacy group for moderate- and low-income Texans.
When people learn about the coverage gap, they are surprised, disappointed and angry, she said.
A new campaign from several community groups, "Texas Left Me Out," aims to put pressure on elected leaders to do something about it.
To better understand what states are doing to make health reform a reality, Keith and Georgetown's Kevin Lucia reviewed new actions taken by all 50 states and the District of Columbia between Jan. 1, 2010, and Nov. 1, 2013, to implement or enforce the Affordable Care Act's market reforms.
Thirty-two states and the District of Columbia passed new legislation or implemented regulations to carry out at least one of the Affordable Care Act's health insurance market reforms.
The law's market reforms protect patients by prohibiting health insurers from rejecting people based on preexisting health conditions, for example, and covering a minimum set of essential health benefits.
Seven states, including Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Oregon and Vermont, have "fully embraced" the three major components of health reform by implementing market reforms, establishing a state-based marketplace and expanding Medicaid, the research team found.
Sixteen states and the District of Columbia have established their own health insurance marketplaces, or exchanges.
"It's very encouraging that nearly all states have taken some steps toward implementing or enforcing the Affordable Care Act," Sara Collins, the Commonwealth Fund's vice president for health insurance, said in a news release from the foundation.
"Already we can see the positive impact of their efforts as millions of people are gaining health insurance coverage through expanded Medicaid and the health insurance marketplaces," she pointed out.
"However," Collins added, "it is concerning that some states have taken only limited action, or none at all, since their low-income and uninsured residents in particular may not be able to fully benefit from the law."