Jim is a 56-year-old man with diabetes who has been my patient for several years; he is a subcontractor in the construction field in a county seat. (I changed his name and those of others whose examples I cite in this blog.) He is divorced with grown children and is devoted to his grandson. He has been uninsured for years due to his medical problems. Starting January 1, he will have health insurance through the Exchange, which allows people to explore subsidies and to compare and sign up for plans. An insurance agent who would not have had any options to offer my patient last year drove to Jim’s home twice from metropolitan Des Moines to set him up with his new policy.

Bob is a 63-year-old man with diabetes and serious liver disease; he has been my patient for several years while working in a supervisory position. He lost his job and his health insurance this fall. My health coach, acting as a certified application counselor (CAC), signed Bob up for a health-insurance policy, starting New Year’s Day, via the Exchange.

Gloria is a registered nurse with five children who has been without health insurance through her job. She is signing up for Medicaid via information found on the Exchange.

A close relative who owns a family business in a county seat in rural Iowa was able to find health insurance for himself and his wife through CoOportunity Health that will save him $800 per month.

My niece, who lives in Texas but was home for the holidays, used the Exchange to find affordable, comprehensive health insurance. She was also helped by my health coach/CAC, whose role is one that has become a key piece of the process nationwide. The head of the Colorado Exchange has said that Colorado has found that many if not most of its users have needed the help of a live person to sign up for health coverage via that state’s Exchange.

I could recount the stories of several other patients who will continue to see me in 2014 with health insurance newly available to them because of the Affordable Care Act (ACA).

Despite the inexcusable delays, hassles, and screw-ups, more than 2.1 million individuals in the United States will have insurance coverage in 2014 found through the Exchanges.

For all of this, I am thankful.

What I am not thankful for is the fact that Iowa does not have a state-based Exchange that would have signed up many thousands more Iowans, that would not have caused the temporary loss of Medicaid for 16,000 Iowans (due to a miscommunication between the federal Exchange and Iowa Medicaid), and that would not have exacerbated the public perception of a flawed rollout of this very important project.

Iowa needs a state-based Exchange; the Des Moines Chamber of Commerce says so; John Forsyth, CEO of Wellmark Blue Cross and Blue Shield, says so; thousands of Iowans who will not have their health coverage on January 1, 2014, say so.

We now have a blueprint for such an Exchange: Let us use the nonprofit, nongovernmental approach that Colorado has chosen for its Exchange, and let’s design our website using the website contractor that Kentucky’s Exchange selected. Both states’ enrollment numbers have far surpassed Iowa’s.

Colorado’s Exchange is a nonprofit entity that uses no general state dollars; startup costs were paid from conversion of the state’s high-risk-pool monies and federal dollars; the Exchange will be self-sufficient based on a premium fee for policies sold on the Exchange. Four advisory groups representing consumers, health plans, and small businesses provide feedback to the Colorado Exchange’s Board of Directors, which was established by the Legislature. Kentucky has the most user-friendly Exchange website this side of www.theHealthSherpa.com, which is an amazing site worth checking out. HealthSherpa gives each individual an accurate, detailed listing of health insurance options anywhere in the United States, including subsidies, after only two clicks of a mouse and typing in age, ZIP code, and income.

If I have an appointment with an uninsured patient, I print the listing of health Exchange options as per the HealthSherpa website for that patient during my clinic visit with him or her.

My final thought: If, as I believe, the Iowa Legislature will not have the wherewithal to create a state-based Exchange, maybe a nonprofit entity should be formed in Iowa to seek a federal contract to run the Iowa Exchange for the federal government.

As I said in July when I started this blog, we have a lot of work to do in order to fully actualize the benefits of the ACA. As we enter 2014, that statement has not changed, but for millions of Americans, 2014 will be a better year because of this effort.

For that, I am thankful.