By Kevin Lucia, Georgetown University Health Policy Institute's Center on Health Insurance Studies

When a child turns two, it's natural to take stock of all the milestones they have achieved such as first steps, first words and first solid foods.  Some parents are even organized enough to document all these achievements in a baby book.  As the Affordable Care Act turns two, we have a scrapbook of sorts to share with you on all that the ACA has achieved in its 24 months of existence.

Just as it takes a village to raise a child, it took three of us here at the Georgetown Health Policy Institute (Katie Keith, Sabrina Corlette and Kevin Lucia) along with the generous support and guidance from the Commonwealth Fund to produce our report.

We found that 49 states and the District of Columbia have already taken their "first steps" supporting the law's implementation, such as passing legislation, issuing regulations or other guidance, or actively reviewing insurer filings. Early insurance market reforms in the law, including new rules for insurers such as bans on lifetime limits on benefits and dependent coverage for young adults up to age 26, are already hard at work helping consumers.

Our report is the first to assess state action on 10 early reforms, including those known collectively as the Patients' Bill of Rights, which went into effect in September 2010. We found that 23 states and the District of Columbia had taken new legislative or regulatory action on at least one of these reforms, and an additional 26 states had taken other action to promote compliance with the reforms, such as issuing bulletins to insurers.

The reforms in the study include:

* expanding dependent coverage for young adults up to age 26,

* prohibiting lifetime limits on health benefits,

* phasing out annual dollar limits on health benefits,

* prohibiting preexisting condition exclusions for children under age 19,

* prohibiting rescissions (cancelling insurance, except in cases of fraud or intentional misrepresentation),

* covering preventive services without cost-sharing,

* expanding coverage of emergency services,

* allowing choice of primary care provider,

* allowing choice of pediatrician, and

* allowing access to obstetricians and gynecologists without a referral.

Here are some other important milestones that have been achieved:

* Twelve states--Connecticut, Hawaii, Iowa, Maine, Maryland, Nebraska, New York, North Carolina, North Dakota, South Dakota, Vermont, and Virginia--passed new legislation or issued new regulations that addressed all 10 of the reforms.

* The District of Columbia and 11 states--California, Delaware, Indiana, Louisiana, Michigan, New Hampshire, New Jersey, Oregon, Utah, Washington, and Wisconsin--passed a new law or issued a new regulation on at least one early market reform.

* Fifteen states--Alabama, Arkansas, Colorado, Florida, Georgia, Illinois, Kentucky, Massachusetts, Minnesota, Missouri, Montana, New Mexico, Pennsylvania, South Carolina, and Texas--issued new subregulatory guidance, such as a bulletin to advise insurers of the reforms.

* Eleven states--Alaska, Idaho, Kansas, Mississippi, Nevada, Ohio, Oklahoma, Rhode Island, Tennessee, West Virginia, and Wyoming--reported that regulators were actively reviewing insurer filings for compliance with the reforms even though the state had not otherwise passed a new law or issued new regulations or other guidance.

* Only Arizona had taken no official state action.

These findings show not only that the vast majority of states have taken action on the early market reforms but that states have adopted a range of pragmatic approaches to help ensure that their residents receive the full benefits of the consumer protections promised under the Affordable Care Act.

The ACA is young and there are many great years ahead. As states implement the provisions scheduled for 2014, they will have to be more proactive in their approach given that unlike the early market reforms, many of the new reforms are entirely new and do not exist in state law.