Those wishing for bipartisanship on health care reform could have found it today in Louisville, Kentucky, where several hundred attendees at the annual meeting of the National Conference of State Legislatures attended a seven hour meeting
on "The Patient Protection and Affordable Care Act and the States." Legislators of both parties from already cash strapped states worried throughout about how they would pay for unfunded mandates contained in the historic legislation. While the meeting was cordial throughout, it was dominated by concerns over state finances coupled with questions as to how states would get programs in place ahead of the 2014 effective date for much of the legislation.
Opening the day long session, Joy Wilson of NCSL, in the course of summarizing the provisions of the Act, declared financing to be a "big problem" for the states, adding that the law contains no or limited funding for complex new eligibility system upgrades. States will be forced to add both staffing and infrastructure to implement the new requirements. She also noted that the law's exclusion of illegal immigrants creates problems. While many conservatives praise that nod to law and order, Ms. Wilson noted that it pushed a federal problem (illegal immigration) on to the states, since illegal immigrants will require uncompensated health care services. Including illegals, a representative from CMS estimated that the reform act will leave 22 million people uninsured.
While the state legislators are glad that state authority in the health care arena was retained, they expressed some frustration that much of the collaboration to date has been with state executive branches, bypassing state legislative bodies. Peggy Welch, a state representative from Indiana, told federal attendees that "state legislators need to have a voice in implementation." Meanwhile, even as presenters warned lawmakers that legislation needed to be ready at the start of 2011 in order to develop state processes within the mandated timeframes, federal officials acknowledged that they lacked answers on key issues. Thus, Jay Anguff of the U.S. Department of Health and Human Services admitted that they did not yet know what would be included in essential benefit packages required of health plans participating in the exchanges. He also could not identify the means of establishing the quality ratings to be provided to consumers seeking health coverage through the exchanges. Preparing legislation even while answers to such basic questions remain unknown creates challenges, particularly in "red states," where a majority of voters adamantly oppose the federal law.
Indeed, the cordial tone of the day's program was interrupted only once, when Charles Scott, a Wyoming legislator, suggested that policymakers should broach the question of repeal. That was too much for Iowa senator Jack Hatch, who said he was "not tolerant" of such ideas and argued that state legislators needed to embrace their role in seeing that the lives of their constituents were improved.
Even apart from state fiscal concerns, such improvement may be hard to come by. A panel including Dr. Michael Karpf of the University of Kentucky warned of an impending doctor shortage that preceded reform that will be even worse because of it. Expressing reluctance to accept reforms that would expand the role of advance practice nurses to meet these needs, Dr. Karpf put much hope in possible changes in reimbursement methodologies that would facilitate the development of a health care delivery model known as the "medical home." While that model is becoming an increasingly popular model for reform advocates because it creates more collaboration between specialists caring for a patient while also more properly aligning incentives for health care providers, it should also be noted that it resembles in many ways the closed panel HMO's attempted in the early 1990's and rejected by consumers (and their employers) who wanted a wider selection of health care providers.
Those who thought the passage of reform was a chaotic process may find that they haven't seen anything yet.