Is the Patient Protection and Affordable Care Act a gigantic failure, a huge success—or stuck somewhere in between? A new study on state implementation and overall response suggests the answer lies behind the latter.

Last month, The Commonwealth Fund undertook a state-by-state analysis of the responses to the opportunity to offer health care to all state residents. What the study found was that the majority of states have embraced, to greater and lesser degrees, the primary tenets of the act. The actions identified revealed the trend among states is toward a more complete implementation of the four key components of the act:

• access to coverage for young adults
• a ban on preexisting condition exclusions
• the coverage of a minimum set of essential health benefits
• a ban on lifetime limits for health care coverage.

"The analysis finds that nearly all states will require or encourage compliance with the market reforms, every state will have a marketplace, and more than half the states will expand their Medicaid programs," the private health-care focused foundation reported. "The analysis also shows that federal regulators have stepped in where states have been unable or unwilling to take action. These findings suggest that regulators will continue to help ensure consumers receive the benefits of the law—regardless of the state they live in."

Highlights include:

• 32 states and the District of Columbia have taken new legislative or regulatory action on at least one of the market reforms.
• 11 states addressed all of the reforms studied.
• Seven states fully embraced all three major components by implementing the market reforms—Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Oregon, and Vermont.
• California, Colorado and New York nearly met this standard.
• Alabama, Missouri, Oklahoma, Texas and Wyoming fully declined to play a role in implementing these components.

"Of the 34 states with federally facilitated marketplaces, 18 states took legislative or regulatory action on the market reforms. Eleven states are expanding their Medicaid programs, with an additional four still considering expansion," Commonwealth reported.