The found that, nationwide, the number of uninsured Americans dropped from 18 percent in September 2013, to 13.4 percent in June 2014. States that chose to follow the ACA’s provisions most closely, both by expanding Medicaid and establishing their own new health insurance marketplaces, as a group saw their uninsured rate drop nearly twice as much as states that declined to do so.

“Those states that have not embraced those two major mechanisms have had about half of the decline in uninsured,” said Gallup’s Dan Witters. “So there’s a clear difference in the states that have implemented those mechanisms versus those who haven’t.”

Arkansas saw the biggest decline in its uninsured rate, from 22 percent to 12 percent. Kentucky, Delaware and Colorado also saw significant declines.

“To drop 10 percent in the uninsured rate within really just six months is really an incredible achievement,” said Arkansas Surgeon General Dr. Joe Thompson. Thompson lobbied for his state’s unique, bipartisan Medicaid expansion, which uses federal funding to buy private insurance for low income people. He says about 80 percent of those with new, private insurance in Arkansas purchased it with Medicaid subsidies.

“Clearly we are having an impact that benefits our citizens,” said Thompson. “Those other states that have chosen not to make something good happen out of the Affordable Care Act are missing that opportunity on behalf of their citizens.”

Among the states that didn’t expand Medicaid or set up their own exchanges are Georgia, Indiana and Mississippi, all of which saw their uninsured rates drop less than 2 percentage points.

Sam Mims, a Republican state legislator from southwest Mississippi, said the Affordable Care Act is still not the right way to go for his state.

“Access to health care is not expanding Medicaid,” Mims said.  “I still believe Mississippi cannot afford it for several reasons. Mainly from a financial standpoint we simply cannot afford to expand Medicaid and we will not expand Medicaid.”

He said the legislature is taking steps to expand access to health care, such as allocating more money to federal clinics, expanding mental health clinics and working on programs to get more doctors and dentists to the state.

Not every  saw big drops in the percentage of uninsured. Massachusetts and Hawaii  saw declines of less than 1 percentage point, for example. Gallup’s Witters said that’s because those states already had very low uninsured rates prior to the ACA.  California, which fully embraced the law but has a higher number of uninsured than any other state, saw a decrease of 5.3 percentage points in its uninsurance rate, according to the survey.

Kansas saw its uninsurance rate pop up by 5.1 percentage points, and Virginia and Iowa also saw slight increases in their uninsurance rates that were within the poll’s margin of error of plus or minus 1 to 2 percentage points.

The telephone poll was part of the Gallup-Healthways Well-Being Index, and it included more than 178,000 people interviewed in 2013 and more than 88,000 people surveyed in the first half of 2014.

Jeffrey Hess of Mississippi Public Broadcasting contributed to this report.

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It’s been a concern since at least 2012, when the Departments of Justice and Health and Human Services sent hospitals a warning them against using electronic records inappropriately.

The letter followed reporting by the and the that found hospitals that used electronic records were billing Medicare for significantly more than hospitals still using paper records. Computers, the theory goes, make it easier to charge for more procedures or more expensive procedures than a paper record would.

“When I read those articles I thought, that’s interesting, I’m not surprised to hear that people are using tools to sort of maximize revenue,” says Dr. , a researcher at the Harvard School of Public Health.

But a colleague, at the University of Michigan, was skeptical, Jha says: “Her take was that hospitals have already maximized their revenue generation from billing, and the chances that electronic records are somehow going to magically make that even more financially lucrative, she just didn’t buy it.”

So Jha and Adler-Milstein to figure it out. They compared billing records from 393 hospitals with electronic records to 782 hospitals still using paper records. They were careful to make sure the hospitals they compared matched each other in terms of size and status as teaching hospitals or for-profit companies.

“To my surprise, we found nothing,” says Jha. “We found that electronic health records didn’t really change billing practices at all.”

He concludes the study with advice for policymakers: “This worry about excessive billing, the empirical evidence says this should not be a big focus of attention.”

But , a pioneer in the field of electronic health records, says this study does not touch upon the area he believes is key..

“They’re looking in the wrong place,” Simborg says, “I don’t think anybody’s done the study that needs to be done.”

Simborg started designing computerized patient records in the 1960s. More recently, he’s led a pair of government advisory panels on how to guard against fraud in digital health records.

Simborg says Jha and Adler-Milstein only looked at inpatient records, those for people who spent at least one night in a hospital. The real area of concern, he says, is in emergency departments and outpatient clinics, an increasing number of which are owned or run by hospitals.

“Hospitals already have software that helps them [maximize billing for inpatient stays].  They’ve been doing that for years,” Simborg says. What’s new is that doctors in emergency rooms and clinics are just now getting digital record keeping tools, which sometimes prompt them to over-document.

Simborg says he’s seen it happen when he was watching doctors use electronic records he designed.

“I would see that they were documenting things that I know they didn’t do to the patient. And these were not crooks, it’s just kind of human nature about having a tool that’s so easy to click a button that puts in a lot of default information when you’re in a hurry, because physicians are always in a hurry,” Simborg says.

Electronic records that automatically fill in standard protocols for certain kinds of visits, like a well- child check or a Medicare annual physical, can help doctors be more efficient. But if doctors don’t delete things they chose not to do during such a visit, they can end up generating a higher than necessary bill.

Simborg says some systems even suggest ways doctors can modify their patient visits to allow them to charge more.

To Simborg, the warning letter to hospitals from federal regulators was the wrong approach. He says government watchdogs should focus more attention on the software industry.

“They can develop the guidelines that would reduce the likelihood that an electronic record would be abused,” Simborg says, like making it easier for auditors to follow a doctor’s digital record keeping trail. “That’s different than threatening that they’re going to be prosecuted if they do these things.”

Chantal Worzala, the American Hospital Association’s director of policy, says the AHA is concerned about, “insuring we have vendors who are creating products that support compliance with best practice.”

She’s pleased that Jha’s study shows that hospitals aren’t using electronic records to generate bigger bills for inpatient stays, but says the tools are new and will require ongoing vigilance.

“We could all benefit from learning more about how electronic health records work,” Worzala says.

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Carriers generally aren’t proposing big changes in premiums for 2015, nothing that’s dramatically out of line with trends of the last several years.

“Most of the premiums are falling in a range of anything from a 10 percent decrease to a 10 percent increase. That’s where the bulk of them are sitting right now,” said Vincent Plymel, a spokesman for Colorado’s Division of Insurance.

While the proposed rates , they are not easy to compare to 2014 rates.  Consumer advocates are digging into the data and analyzing trends. Most insurers are also talking publicly about their proposed prices.

Colorado’s dominant carrier, Kaiser Permanente, is asking for about a 7 percent premium increase, according to consumer advocates.

“Our goal is to keep rate increases to a minimum,” a statement from the company reads. Kaiser Permanente covers about a quarter of everyone with private insurance in Colorado. (Kaiser Health News is not affiliated with Kaiser Permanente.)

It also won nearly half of the new market created by the Affordable Care Act in 2014. More than 127,000 Coloradans bought policies through the state’s new ACA marketplace, about 75,000 of them using subsidies.

“We believe the past year has shown that Coloradans have embraced our model of providing affordable top-notch care and coverage,” the statement reads.

United Healthcare, which holds about 18 percent of the market, declined interview requests on 2015 rates. Consumer advocates said changes to United’s premiums, if any, are not yet clear.

Anthem, third among the three big players in Colorado with 13 percent of individual and small group policies, says it is lowering its premiums by an average of 5 percent.

Steve ErkenBrack, CEO of Colorado-based Rocky Mountain Health Plans, says his company kept its premiums basically flat. It’s still too early to say how big changes, including a lot more people with health coverage, under the ACA are or aren’t affecting premiums, he says.

“We know who the (insured) population is in 2014, but do we know how they will utilize care? No,” says ErkenBrack.

The newly insured population contains at least some people who were denied coverage before, because of pre-existing conditions. Insurers are still learning how much care is used by people who were shut out of the market before.

“In terms of making sure you don’t have unusual fluctuations, you’d probably want a year-and-a-half to two years of data,” ErkenBrack says.

But Julia Hutchins, CEO of the new Colorado Health-Op insurance plan said they adjusted their rates, “down by 10% on average,” based on what information is available about the newly insured.

“Estimates, although early, suggest that the cost (of covering the newly-insured) is not has high as we estimated last year. And so we were able to take advantage of that new data in setting our rates for 2015,” Hutchins said.

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“Like all great health care breakthroughs, it happened at the International House of Pancakes,” he says, half-jokingly.

Venture capitalists are pouring more money than ever before into digital health start-ups, more than $2 billion so far , according to the venture capital firm Rock Health. They are betting that entrepreneurs can help doctors, hospitals and insurers become leaner – which the Affordable Care Act strongly encourages.

Vockell’s endeavor started back in April, when Medicare released a huge database of how much it . The government health plan for senior citizens and the disabled had kept that a secret for decades.

So when Medicare suddenly dumped an entire year’s worth of data, finally making public millions of transactions, coders like Vockell tried to figure out how to make it useful for seniors.

Enter the I-Hop.

“My kids go there after school one day for funny face pancake lunch,” he says. “There were lots of seniors there. And my kids run around, and the seniors love when they come up and sit with them, and I was like, I could totally use my kids to source a whole bunch of interviews pretty fast.”

His three-year-old in a Batman suit proved a great ice breaker, and over a lot of pancakes, 43 seniors told Vockell that knowing which doctors charge more and less wouldn’t necessarily send them shopping for the lowest price. Seniors generally like their doctors and don’t want to shop for new ones.

Mostly the seniors told Vockell, “I know I have some procedures on the horizon, that I don’t know exactly what they mean that I have to do or what they’re going to cost me, I’d love to get some insight into that.”

They also asked, “could you make the print really big?” Vockell says. And, he laughs, several mentioned, “the blueberry syrup is magnificent.”

So Vockell developed a that helps seniors understand the procedures their doctors are recommending, and the costs, so they can start conversations with their doctors – and they can print the information out on paper, in really big type.

It’s too early to say whether his product will be the hot new topic on the shuffleboard circuit, but it was a winner at the big conference this month in Washington, DC.

Big health care data is the raw material for a whole new segment of the IT sector. Entrepreneurs like Sean Power are also exploiting databases like the price list Medicare released this spring.

“That’s hot,” he says. “Anytime anybody releases a new set of data we get excited.”

Powers’ company, , is based on the idea that software engineers like him can find ways to use big data to save the government or big companies money, and that they’ll share some of their savings with him. There’s tons of opportunity in streamlining health care, he says.

“It’s a great time to be starting a company in the health care data space. I think the gold rush is on.”

Just like a real gold rush, hitting paydirt means lots of prospecting. Entrepreneurs can’t always find the information they really need to make a truly useful product. Dr. Omar Alvi is with a start-up called . Their big idea is to help families estimate future health care spending. So you could type in that grandpa’s got hypertension, mom’s got diabetes and one of the kids has asthma, and then get some idea of how much that’s all going to cost, and maybe even shop for the best price.

A great idea, but, Alvi says: “Each patient is very different, and so in order to be able to make a meaningful prediction, you have to have a lot of data. So you can say, patients just like this went through these problems as they moved through the medical system. That’s really where it requires hundreds of millions of data points.”

And not even close to the millions of data points Alvi’s company needs are available yet. A lot of information about procedures, cost and effectiveness remain locked up inside insurance company computers, or in hospitals’ and doctors’ medical records – information they don’t want to share.

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The marketplaces, including Healthcare.gov and 14 state-run exchanges, are long-term investments. They have to work in the short-term, but also be desirable places for buyers and sellers to get together for years going forward.

In that sense, they’re a lot like other marketplaces, like this flea market in Colorado Springs, Colorado. Buyers and sellers flock , because it’s an easy place for them to find each other and make deals. On a recent Saturday, Dillon Keller was looking to move some roller skates.

“My mother in law works for a roller rink,” he explains, “and these are the ones people left behind for over a year. So, she said, ‘get rid of them!’ “

Keller drove across town and is spending $20 for a little square of asphalt here to sell the roller skates. He could have just had a garage sale, “But it’s not as successful,” he says. “You don’t have near the amount of people. For every one person at a garage sale, you probably have at least 50 out here.”

The flea market does a lot to draw customers in. It has a big billboard next to its highway exit, a food court, and even hires a live band on weekends.

The exchanges are supposed to be desirable marketplaces for health insurance. It’s even the same principle behind the New York Stock Exchange, says Economist .

“You could look at health insurance and see the same thing: Do people want to sell their policies on there? Or is it growing in magnitude? Those are sort of standard metrics of success for marketplaces, and we should apply them to [the exchanges],” he says.

Eight million people showed up to buy insurance on the exchanges in the first six months. But will it be a good enough deal to bring them back? Will more insurers jump in? Holtz-Eakin says we don’t know enough yet to conclude which state’s exchanges are successful.

“I think we know the outliers, we know the big failures in Oregon and Maryland, for example. We know what appear to be the great successes in places like Kentucky, which is quite cheap and have a big fraction of people signed up. In between, it’s pretty hard to make the case we know who’s better than someone else,” he says.

One way it’s tempting to figure out which states were successful is to divide the federal grants sent to the states, by the number of people the marketplaces signed up. That gives a a cost-per-customer.

But comparing states based on that is, “really not a meaningful calculation,” says , an economist at MIT.

He says insurance exchanges are long-term investments. They should last for decades and every state that set up its own had similar up-front costs, like hiring technology companies to create their online shopping sites.

“A lot of the programming, the computer set up is the same regardless of how many people enroll. So, by that number, California is going to look better than Rhode Island,” Gruber says. “If you infer from that that California is better than Rhode Island, it’s sort of like inferring that we should never let small states do anything.”

It’s also nearly impossible to compare Healthcare.gov states with those that did their own exchanges, based on the financial information the White House is releasing so far. And some states got millions or tens of millions of dollars in outside help from private donors. Even .

There’s just not enough information right now for economists like Holtz-Eakin pass judgment on the Affordable Care Act’s marketplaces. He says they’re only part of the picture of the federal health law’s success anyway.

“I think the focus on the exchanges per se is a natural fallout from Healthcare.gov melting down at the beginning,” he says, “but it’s really not the right metric for success or failure.”

Economist Jonathan Gruber agrees.

“Success can really only be defined ultimately as a significant improvement in the well-being of the US public – uninsurance rates drop, seeing health improved, seeing bankruptcies drop.”

The public won’t know whether that’s what they got for the tax money they spent on exchanges until well after this November’s elections.

Next year, though, federal grant funding for state exchanges starts running out. The challenge for these new marketplaces now is to grow on their own. Most have still only enrolled of the uninsured people in their states.

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The numbers could reveal fraud. But experts caution that the raw data alone could also make physicians who are doing nothing wrong look bad.

Findings are based on an analysis of a database assembled by , an independent, nonprofit newsroom. The data show payments made according to the system of codes for routine office visits doctors use to bill Medicare and insurance companies.

Office visits are reimbursed on a scale between one and five, with five being the most intensive and costly. So, a quick, easy visit should be coded at level one, meaning a relatively small payment.  A level five charge is meant for the longest and most difficult visits, which are also paid at a higher rate.

The national average for providers who bill Medicare Part B at the highest level is 4 percent. In Colorado, the average grows to 5.4 percent.

Red flags

Dr. Aris Sophocles, who practices in Denver, says anyone who bills at the highest level frequently deserves an investigation.

“It could mean that someone’s gaming the system and overcharging Medicare,” Sophocles says.

Sophocles teaches medical coding to medical students and doctors. He also works as an attorney, helping to defend doctors accused of improper coding.

What’s especially curious to Sophocles are doctors who bill at the highest level for 100 percent of their Medicare patients.

“I expect physicians to see both complex patients and simpler patients,” Sophocles says. “I expect them also to have longer initial office visits, but the majority of subsequent visits being shorter.”

In 2012, the most recent data available, 71 Colorado health care providers billed at the highest level 100 percent of the time. Sophocles says that figure could reveal fraud, but cautions that it also might not. He says each of those doctors deserve an opportunity to explain why their billing rates are so far outside the norm.

Some doctors justified

Kaiser Health News attempted to contact 15 Colorado doctors who billed 100 percent of Medicare office visits at the highest level. Most of them didn’t return our phone calls. But several did, including , the director of transplant infectious disease at the University of Colorado at Denver.

Levi says she’s justified in billing all of her Medicare office visits at the highest level because she works at Colorado’s only academic medical center. It’s the place other hospitals all over the region send some of their toughest patients.

“The time that is required to take care of them is longer than some of the other specialties in infectious disease,” Levi says.  “That’s the reason for the longer time periods required for their evaluation and treatment, and that results in the higher coding.”

That kind of information isn’t obvious in  of Medicare payment data that was made public for the first time in April 2014.

The American Medical Association fought public interest groups pushing for its release for years because properly interpreting billing codes can be complicated. Dr. Levi is concerned people will misinterpret them.

“There has to be an understanding and recognition of specialty care that is provided in only a few places.” Levi says. “I think it’s dangerous to lump everyone together and base everything on a code.”

Other prominent physicians share Levi’s concerns, even as they support making more price information public.

Price transparency is a goal

, the chief medical officer at , says price transparency is a good thing.

“I think consumers should be aware of the costs of the care that they’re receiving,” Cohen says.  “The caveat is, when they evaluate physician-to-physician, they have to be certain they understand the patient mix that any given physician sees. Their coding may be very appropriate even though it’s higher than another physician they’re comparing to.”

Sophocles agrees, but he says some specialists are more likely than others to have a mix of mostly complex cases that justifies billing at a high rate most of the time.

“When I see someone in family medicine [billing frequently at the highest level], I get suspicious,” Sophocles says. He also says the same is true for other specialties, such as general internal medicine, otolaryngology and gastroenterology.

Medicare tells ProPublica it would be “highly unusual” for a doctor to bill at the highest level 100 percent of the time. The agency audits doctors, and those who don’t code properly.  They can be required to pay Medicare back – and may face jail time.

Those consequences, Dr. Sophocles says, cause a lot of doctors to bill less than they maybe should, a practice called undercoding.

“Some, though, are either unaware or unafraid,” Sophocles says.  “They tend to overcode anyhow. The release of this database may indicate who those people are.”

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Local officials in the ski resort region in the mountains west of Denver had over the high rates. But on Friday Colorado Insurance Commissioner Marguerite Salazar said she wants to redraw those boundaries, making the resort counties part of a much larger 22-county pool.

The Affordable Care Act sets a lot of limits on what insurers can do – they can’t charge sick people more, for instance – but one thing that still counts is location, location, location. Premiums can be higher or lower based on how much doctors and hospitals cost in a specific area. And states get to draw those geographic boundaries. When Colorado lumped together Garfield, Pitkin, Eagle and Summit counties — an area that includes the towns of Aspen and Vail — the state created the most expensive insurance market in the U.S., almost by accident.

“It is about fairness,” Salazar said, explaining the new boundary. “When we put (the resort counties) together, we didn’t know what the difference and disparity was going to be. We found out pretty quick.”

That’s a switch from what Salazar was saying in December when she argued that it wouldn’t be fair for some of the state’s poorest counties to subsidize its richest by putting them in the same risk pool.

Local elected officials like Dan Gibbs from Summit County welcomed Salazar’s proposal, saying, “the status quo was killing our middle class.”

But if re-drawing the rating map has the effect Salazar predicts, resort county residents will still have some of the highest ACA premiums in the country.

The current premium for a 40-year-old non-smoker in the resort counties is $483 a month. Salazar says her best guess is that rates would drop 4 to 8 percent in those counties, bringing the premium down to $444 to $464 a month.

Rates would go up in the non-resort counties. Salazar says prices could rise 4 to 6 percent, which would drive the cost of a comparable plan up from $349 a month to about $366.

The new of premiums and what drives the costs has some county officials meeting with local hospitals to at least study costs and look for strategies to bring them down.

Actual rates for next year are all speculation until June 6, when insurers have to submit proposed premiums for 2015.

So far there’s been no backlash from people in counties whose premiums are likely to rise. Commissioner Salazar is taking public comment until Wednesday, and plans to issue a decision Friday.

Beyond next year’s rates, another announcement Friday will surely influence health care prices in Colorado’s resort area. Kaiser Permanente, the state’s dominant health insurance company announced it will enter the western Colorado market in 2016. Kaiser hasn’t said which specific towns it will serve, or to which facilities it will send members for care, but increased competition could drive prices down. (Kaiser Health News is not affiliated with Kaiser Permanente.)

This story is part of a reporting partnership between NPR and Kaiser Health News.

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