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The website for Connect for Health Colorado, the state's health insurance exchange, shown in October 2018. (Eric Lubbers, The Colorado Sun)

The Colorado legislature this year passed some of the most ambitious health insurance reform measures in years — first-in-the-country kinds of programs that could place the state on the leading edge of health policy nationwide.

Statistically speaking, you aren’t likely to see a direct impact from many of them.

That’s because some of the biggest policy changes focus on an insurance market that provides coverage to only about 8% of Coloradans. It’s not an insignificant number — it still represents more than 400,000 people. But it means that the vast majority of Coloradans won’t see direct benefit from, say, a measure to create a government-backed insurance plan that can offer lower rates than what are currently available. Or one to help insurance companies pay high-cost claims in order to bring down premium prices for everyone.

Statewide, about half of Coloradans receive health insurance through their employers. About 35% of the state receives insurance through government programs, and almost 7% of people are uninsured.

That leaves the rest in what is known as the individual market — the place where people buy insurance coverage on their own, sometimes with help from federal subsidies but often not. This is where lawmakers spent much of their session debating, tweaking and voting. And here are three reasons why that is:

The cost

Health insurance is expensive for nearly everybody, but nowhere is it as expensive as in the individual market.

“The individual market is the only place in our health care system where people don’t have any help in purchasing their health insurance,” said Michael Conway, Colorado’s top insurance regulator.

With Medicare or Medicaid, taxpayers pick up at least part of — if not the entire — the tab. With employer-sponsored coverage, the employee typically pays only about a third of the monthly premium. And, even in the individual market, government subsidies for people with lower incomes can sometimes knock monthly premiums down to almost nothing.

But people in the individual market who make too much to qualify for subsidies are paying full freight. And that can often be more than $1,000 a month just to cover one person. It can also lead to what Conway calls “the really scary stories in our health care markets,” where people are choosing between paying for coverage or paying their mortgages.

“The individual market is where we have seen the most dramatic increases and where we have heard the most concerns about affordability,” said state Sen. Kerry Donovan, a Democrat from Vail who sponsored a number of the health insurance bills this year at the Capitol.

Donovan said the health care costs of people in the individual market have been the No. 1 issue she’s heard about from voters during the past couple of election cycles. Even people who have insurance through their employers talk to her about it — because they know someone who is suffering from individual market prices.

“No one has ever told me to spend less time on health care,” she said.

The impact

Conway’s title — commissioner of insurance — perhaps oversells his authority a bit when it comes to health coverage.

The state Division of Insurance has regulatory power over only about a third of the total health coverage market. Not only are Medicare and Medicaid outside of its purview, but so are self-insured employer plans, which make up about half of all employer-sponsored plans. That means the individual market comprises about a quarter of what’s under the Division of Insurance’s authority.

It’s also a more transparent market. While information on most employer-sponsored plans — and, especially, on what workers have to pay for those plans — can be scant, prices for plans on the individual market are easily found on the website of Connect for Health Colorado, the state’s insurance exchange.

This gives lawmakers an added incentive to address problems in the individual market. Fix them and everybody can see it.

“It’s kind of like, if you drop your keys at night, why do you keep looking under the streetlight?” said Joe Hanel, a spokesman for the nonpartisan Colorado Health Institute. “Because it’s dark everywhere else.”

The bigger meaning

The third reason for lawmakers’ attention has less to do with what the individual market actually is and more to do with what it represents. Basically, it’s become a beeping EKG monitor for the health of the Affordable Care Act.

The ACA so dramatically affected the individual market that sometimes the coverage choices in it are referred to as “Obamacare plans.” The ACA created the now-famous rules for what plans sold in the individual and small-group markets have to cover. It created the exchanges where many (but not all) individual market plans are sold. It created the mandate that everyone have health insurance — which sent previously uninsured people to the exchanges to begin with.

“It’s the marketplace that people associate with the Affordable Care Act,” Conway said. “When people think about the ACA and all the political dynamics that go into the ACA, they are typically talking about the individual market.”

That makes any fight about reforms to the individual market also inherently about the bigger question of whether the ACA is succeeding or failing. And, for Conway and a lot of especially Democratic lawmakers, that makes fixing the individual market sort of a prerequisite before moving onto reforms that will impact more people.

“We have to figure out a way we can stabilize the individual market,” Conway said, “so we can focus on making more systemic changes across the board.

John Ingold is a co-founder of The Colorado Sun and a reporter currently specializing in health care coverage. Born and raised in Colorado Springs, John spent 18 years working at The Denver Post. Prior to that, he held internships at the Rocky Ford Daily Gazette, the Colorado Springs...