County issues addressed

Like the cities, NACo members are particularly concerned that the costs of health care are not passed from the federal and state governments to the local level, where much of the direct service is provided. More specifically, Beddoe says, they want to ensure that payments to county hospitals are not reduced in such a way that passes increased overall costs to governments. "If arbitrary cuts are used as offsets, we may go back [to Congress]," he says.

Local officials worked to include a provision that protects counties by stopping states from requiring counties to contribute a higher percentage of the nonfederal share of Medicaid than they did in 2009. The reform also includes support for a National Health Service Corps that helps place health care professionals in medically underserved and rural areas, which is a primary concern of rural counties.

One issue of continuing concern that received partial resolution is how to handle Medicaid eligibility for inmates in county detention facilities. Currently, inmates who are only in jail because they cannot post bond, but have not yet been convicted of a crime, are ineligible for coverage under Medicaid, which is paid by the federal and state governments. Counties believe that the cost of that health care should be borne by Medicaid until conviction and sentencing. Under the new law, Medicaid will cover some of the inmates, but the largest portion remains the counties' responsibility. "We're still hoping to fix this [for the broader group]," Beddoe says.

Overall, though, he says counties "came out pretty well on the key priorities." While NACo as a whole did not take a position on the legislation, its health steering committee unanimously endorsed the legislation, he says. "Health care has a very big budget impact on counties," Beddoe says. "The counties bear a great deal of the safety net responsibility. Social inequities ripple out into the health care system and into the community at large. Improving access to the health care system will alleviate a lot of the social problems downstream."

As a provider at the local level, Langston sees how the new legislation may help build a health system that improves overall care. "The change will allow for more efficient care for people," she says. "The biggest challenge is people with chronic diseases. This allows a whole process to assure that everyone gets into the health care system effectively."

She notes that while Washington often responds to the perceived need, the actual responsibility for delivering health care reform lies largely with cities and counties. "At the federal level they have great ideas, but [they have] no idea if it can be implemented at the local level," she says. "A lot of the money will go to the states. We have to make sure that there is a smooth transition of the money to the local level."

Part of Langston's efforts will be to explain the provisions of the bill to area residents. "We need to have a conversation about the real things," she says. "It's a 2,500-page bill. Whatever side of the spectrum you're on, we have to focus on what we want to accomplish. We have to make it real in the context of people in their own lives."