Small steps to a big law

With the political winds swirling and legal challenges mounting, state and local government officials might be tempted to take a cautious approach to implementing the provisions of the massive federal overhaul of health care enacted just a year ago. But, too much caution on health care reform might put them at a disadvantage in a few years if the Patient Protection and Affordable Care Act (PPACA) withstands court battles. “It’s full speed ahead,” says Supervisor Liz Kniss of Santa Clara County, Calif. “If we hesitate, we lose a great deal of ground. There’s too much to be gained to stay put and keep the brakes on.”

While some state governments, especially those headed by Republican governors and legislatures, are fighting the mandates and reforms in the PPACA, many state and local agencies are acting to bring about the necessary changes in their programs to implement the new system. Not all government leaders are enthusiastic about the new law, although they are ready to accept its inevitability. “It’s highly unlikely that it will be repealed in its entirety,” says Randy Johnson, the Republican commissioner for Hennepin County, Minn., in the Twin Cities area. “We are trying to move ahead, assuming that it will remain intact.”

Questions abound

Without doubt, the full rollout of PPACA would substantially change the delivery of health care services in the public sector. Before it can be fully implemented in 2014, though, the law will have to survive legal challenges brought by over half the states in federal courts against the central provision that all Americans have health insurance (or be subject to a penalty), which may not be resolved by the U.S. Supreme Court until the middle of 2012. In addition, a change in control of the White House as a result of the national election in 2012 would likely ensure substantial repeal of the legislation.

At the state level, the immediate challenge for officials is to create health care boards, team leaders or responsible agencies to implement PPACA, even in states where their attorney general is fighting the law in court. In particular, the states’ challenges are focusing on a primary responsibility of the legislation to create health care exchanges. The exchanges are intended to become open markets where an estimated 24 million people, who are uncovered today, eventually will be able to buy private health coverage, most with the aid of federal subsidies. Although some states have rejected federal funding for pilot programs, the vast majority have taken at least tentative steps toward implementing their portion of the law.

However, another huge responsibility of the legislation is providing health coverage to the poor who are currently unable to purchase insurance. When it comes to the on-the-ground delivery of care to the poor and uninsured, the responsibility falls to county governments. The tenuous legal and political environment raises concerns about whether county officials should devote government resources to implement programs that may never see the light of day.

“It’s a tough question,” says Anita Cardwell, the health care point person for the Washington-based National Association of Counties (NACo). “It’s very important for counties to pay attention to what is happening.”

Through a variety of committees, NACo is trying to influence how PPACA’s programs are drawn up by the regulators in Washington, especially the Department of Health and Human Services, which has the primary responsibility for many of the law’s critical provisions. It is also sponsoring a series of webinars to keep its membership current on the implementation process.

NACo is fighting efforts by some congress members, for example, to convert Medicaid from a mandated program to a block grant program, because it fears that states will shortchange the counties and the eventual cost of providing services will fall on local governments. In addition, in 2014, when the PPACA expands Medicaid to include all eligible individuals who have incomes up to 133 percent of the federal poverty level, the program could operate more like commercial insurance and less like a safety net program, according to some analysts.

In anticipation of higher costs, states are currently determining where to make cuts that will not damage the program in the long term and maintain the current quality of care mandated by the law. Counties want to make sure that the financial burden does not roll downhill to their residents. “If fewer people are covered by the state, the locals will have to pick up the cost through county hospitals,” Cardwell says.

Another area of special interest to counties is the Prevention and Public Health Fund, which dedicates PPACA funding for state and local prevention and public health activities, totaling $15 billion over 10 years. Counties want to review those plans before states enact them, according to Cardwell. “We are trying to keep counties informed on the general situation and keeping the regulators pointing in the right direction,” Cardwell says.

While county organizations are working to keep their membership apprised of the activity in Washington, local governments are looking to familiar sources for insights. In California, for example, more than 600 employers attended a series of seminars sponsored by Torrance, Calif.-based Keenan & Associates, a large insurance broker serving governments in the state. Two years ago, just 200 governments attended similar programs, says Henry Loubet, the company’s chief strategy officer.

One Keenan client, Glendale, Calif., was able to take advantage of a provision of the PPACA called the Early Retiree Reinsurance Program that offers aid to employers to reduce early retiree health care costs, says Matt Doyle, the city’s director of human resources. “We’ve received reimbursement of $179,000 from the federal government so far, and we anticipate more reimbursement,” Doyle says. “It could amount to $400,000 per year. It’s fantastic.”

The view from local governments

The law is somewhat of a mixed blessing for Hennepin County, Johnson says, given that it will “suck a lot of dollars out of the state,” which has been a leader in health care reform. As an example, he notes that the law offers significant funding to promote the conversion of the health care system to electronic medical records. But that will not help Hennepin County, because it has substantially completed the process locally. “No good deed goes unpunished,” he says, glumly.

At the same time, Hennepin County will receive an additional $42 million in Medicaid reimbursements because the new Democratic governor reversed the decision of his Republican predecessor and will now accept federal assistance to expand the PPACA-authorized program. While acknowledging that many fellow Republicans opposed the new governor’s decision, Johnson says he supported the change because the alternative was worse. “Either the indigent would not get care, or the cost would have come out of property taxes,” Johnson says. “Neither was a good option.”

Sonoma County, Calif., has been taking a methodical approach to the new law, says Supervisor Valerie Brown. “We’ve looked at it piece by piece,” she says. “How can we take advantage of it until 2014? How will it be of value?”

Brown recently attended meetings in Washington with 17 federal agencies that are drafting regulations to promote prevention and improvements. Their theme is that investing more on prevention of root ailments like diabetes and obesity will result in overall cost reduction, because chronic diseases consume such a large portion of health care spending.

She says she was encouraged that PPACA has spurred a huge range of activities across the government. “You always need some kind of directive to get things done,” she says. “It’s too easy to nod and say, ‘Yes.’ Without an action plan, nothing will happen.”

Brown says that a number of provisions are already helping people with pre-existing conditions and children under the age of 26 who are now covered under their parents’ medical plan. She agrees that despite the challenges, the law is unlikely to be abandoned. “You can’t throw the baby out with the bath water,” she says. “They’re not throwing the whole thing out. The longer people live with the new system, the more comfortable they will feel.”

Steps toward implementation

In some cases, counties have contributed their own tax dollars to cross-government PPACA-related initiatives to participate in leading-edge programming. Linda Langston, supervisor of Linn County, Iowa, says her government took “a leap of faith” by investing $45,000 in a new website that will help diabetics monitor their care.

“It’s a great tool,” she says. “They can find information on all recent articles about diabetes. Find out things they have in common with others. It tracks legislation. It puts the individual in charge of their health record.”

Langston, whose county includes Cedar Rapids, says that counties need to monitor PPACA closely because the law includes a variety of funding mechanisms supporting community health care, which is a primary responsibility for many counties.

“The concept that underlies PPACA is, ‘How do we build community?'” she says. “It can’t be an edict. The community has to be the mover. We cannot do this through a top-down approach. We can only change behavior through a partnership at the local level.”

She says that familiarity with the law’s provisions will change attitudes as more benefits become apparent. “Once programs begin to evolve and it is seen that the goals are attainable, it will demonstrate to other communities that we can accomplish big stuff,” she says. “It’s a tough climb, but it’s a positive that the administration is open to putting county officials on the rules-making committees. It shows they’re responsive.”

The future of health care

For Supervisor Kniss, the entire process from the passage of PPACA to now, when its core mandate is under legal assault, has been “a roller coaster ride.” “I was at the bill-signing,” she says. “It was so exciting. It was amazing that it got signed. It was quite dramatic. It’s the law of the land, but will it be funded? How well will it be funded? Is there any possibility that it will be repealed?”

Kniss says that the law has had an impact in the year since it was passed. “In a nutshell, there has been a 180-degree turn in health care,” she says. “The health care funding system has changed. The system has changed. There’s been a new emphasis on pay for performance.”

When she speaks to students about health care, they can hardly believe when she notes that most doctors still keep their records in tan folders, which are updated with sheets on a clipboard. “How far behind we are in the technology,” she says. “The kids just laugh. It’s beyond their comprehension.”

The PPACA aims to convert the whole system to electronic health records by 2014 when the full law is implemented. “Any system is doomed if it has to carry on as it has before,” Kniss says. “We have to go modern, go electronic.”

She also supports the law’s focus on prevention. “It’s an integral part of the PPACA,” Kniss says. “It’s as much to keep people out of the clinics in order to promote a much healthier lifestyle. A healthy population spends much less on health care. There are dollars and cents and motivation for those who want to keep healthy.”

Kniss, who is chair of NACo’s Health Steering Committee, acknowledges that some of her county colleagues are not as supportive of the legislation as she is. “We’re not all on the same page,” she admits. “There’s a considerable difference of opinion. Some feel that it takes states’ rights away, that health care is the responsibility of the private citizen.”

Still, as a former public health nurse, Kniss believes that once people become more comfortable with the legislation, the division and bitterness will pass. “We’ll look years from now and be amazed that it was so problematic,” she says.

Robert Barkin is a Bethesda, Md.-based freelance writer.