Two renowned world leaders have offered “facts” in famous quotations that have bearing on the state of an Iowa health-care Exchange.

Prior to the American Revolutionary War, John Adams, one of our most famous patriots, took on the controversial role of defending British soldiers who had fired on a Boston crowd of protesters. In his successful legal defense, he uttered the famous statement, “Facts are stubborn things.”

On May 10, 1940, the day Nazi Germany invaded Belgium, The Netherlands, and France, Winston Churchill became the prime minister of the United Kingdom. After years of being outside of leadership, criticizing that leadership for appeasing Hitler, and preparing himself to lead what he foresaw as the ultimate fight against the Axis, Churchill said, he slept well that night because he was confident that “destiny” had prepared his country and him for this fight. He finished this discussion of his confidence by saying, “Facts are better than dreams.”

Starting October 1, the Iowa Exchange, which is now referred to as the Marketplace, will allow Iowans to buy health insurance, some at subsidized rates based on individual or family annual income, as well as allow other Iowans to sign up for Medicaid. This Exchange (Marketplace) is called a hybrid Exchange because both the federal government and the state of Iowa are managing different aspects of it.

The “stubborn” fact is that this Exchange should have been a pure state Exchange like those of so many other states, such as Colorado and Minnesota, allowing each to custom fit a process for its residents. A state Exchange, in my mind, would have 1) created a more user-friendly process for Iowans to access health coverage, 2) made it easier to adapt the process as the need for changes became obvious, 3) allowed Iowa to receive tens of millions of dollars to publicize and then access the Exchange, and 4) most importantly, given Iowa more ownership in this health-reform effort, which would have led to more emphasis on public awareness, education, and adoption.

The state’s Legislative Health Care Coverage Commission, which I led for two years, submitted detailed reports each year regarding the creation of an Iowa Exchange. A workgroup labored many hours developing recommendations, which the full commission then approved. In addition, the state of Iowa received millions of federal dollars to investigate and prepare for health reform, including the creation of an Iowa Exchange. Yet, at the end of the day, we were told that Iowa, a leader in health care in many ways, could not create its own Exchange and would be forced to sign on to a hybrid Exchange, abrogating our ability to customize the process for Iowans in favor of a one-size-fits-all federal-government approach. The Exchange will be live October 1, and Iowans signing up will receive health coverage either through health insurance or Medicaid on January 1, 2014. Yet, the “stubborn fact” is that it could have been so much more under different circumstances.

Nonetheless, “facts are better than dreams”; we have the capability in our state to create a top-notch system of health coverage for our residents. The pieces of the puzzle are on the board for us to put into place. We will have an Exchange (Marketplace) where individuals will access affordable options for health coverage; we will have options for health coverage both within the Exchange (CoOportunity Health, Coventry, and others) — the premium rates announced on September 20 are some of the lowest rates in the country — and outside the Exchange (Wellmark, CoOportunity Health, and others); we already have an environment of health providers that provides quality, efficient care; and we already have a populous who care about their health and will take efforts to improve it. The challenge is putting the pieces together.

So let’s get to work.

Our current topic is how to make the Exchange successful. Success will require 1) motivated individuals to become informed, 2) informed individuals to maximize current services or create services that allow our residents to fully utilize the Exchange starting October 1, 3) these services to become known to the public, and 4) the public at large to sign up for health coverage via the Exchange, either individually or with the help of these currently available or newly created services.

Signing up for insurance coverage via the Exchange can occur in one of four ways:

1. Directly: An individual can access the Exchange via a computer.
2. With help: An individual can work with an insurance agent.
3. With help: An individual can work with a vigorously trained layperson called a navigator.
4. With help: An individual can work with a less-trained layperson called a certified application counselor (CAC).

Steps 1 and 2 are self-explanatory, but the other steps refer to newly created positions. Navigators work for entities that have received federal grants to pay for this service. In Iowa, three entities — Genesis Health System in eastern Iowa, Visiting Nurse Services, and Planned Parenthood — received grant monies for certain counties. Unfortunately, 27 counties — more than one-quarter of Iowa counties — mostly in northern Iowa, have no access to navigators. The white area on the map below indicates Iowa counties without navigators. It is a significant portion of Iowa counties.

CACs are volunteers or staff affiliated with various entities, including hospitals, physician groups, community health systems and others, and they are trained by the federal government to provide assistance to individuals signing up on the Exchange. In my clinic in Ames, my health coaches are certified CACs and will provide this service for my clinic’s patients. A listing of trained navigators and CACs by county will be available on a federal registry.

From a proactive stance, concerned individuals ought to know what resources are available in their counties. Given that no further navigator grants are possible, the only way to increase capacity is to add to the list of CACs. I would recommend that people communicate with their local hospitals and physician groups and determine whether to congratulate them because they have CACs on staff or to instead ask them to apply to be designated as CAC organizations and then certify their staff as CACs. Every Iowan who qualifies to use the Marketplace should have the expertise available to them so they can access the Exchange successfully.

A key element for health reform for me has always been the success of individuals utilizing the Exchange. In my mind, health reform succeeds or fails based on the workings of the Exchange. I encourage everyone to access, promote, and help others to utilize the Exchange, starting this October 1.

A future topic for me will be the “culture of coverage,” which starts with the successful accessing of the Exchange. I look forward to presenting ideas of how Iowa can promote a culture of health coverage across the state.

One additional musing: I can envision successful Democratic state candidates using activities such as a “Braley Bus” or a “Hatchmobile” containing CACs going around the “orphan 27 counties,” helping individuals sign up with the Exchange and creating name recognition and good will.

I close with a return to the idea of “facts.” The Exchange represents probably the most tangible, identifiable, citizen-interactive element of the Affordable Care Act. Every week I see patients with no health insurance, at greatly reduced or no cost, who are being denied health-care options; every week, I know there are patients of mine who should be coming to see me for health concerns but do not because of a lack of health coverage. In hospice, I recently cared for a 50-some-year-old woman with cervical cancer that was ravaging her body; without health insurance, she never received the preventive health care that should make dying from cervical cancer impossible in our society. Iowa’s Exchange could have been better, but, even so, I believe it will improve and save lives by finally allowing thousands of Iowans — my patients included — to receive and benefit from previously unobtainable health care.