With their ties to both the business and health care sectors, hospital trustees are expected to play a pivotal role in promoting the health reform law within their communities and among politicians. But given speculation that the House of Representatives' new Republican majority may stymie implementation by withholding appropriations, legislating alternative policies and investigating the political machinations that produced the law, trustees are seeking guidance from hospital executives on how to advocate amid a polarized debate.

"This is unprecedented confusion and undoubtedly the murkiness will cause us all to be conservative," says Scott Malaney, president and CEO of Blanchard Valley Health System, Findlay, Ohio. He believes it's OK for trustees to acknowledge these uncertainties. "We don't control what will happen in Washington and the statehouses, and part of transparency is telling people what you do and don't know. Saying there will be curveballs ahead is good management."

Support for the law nationwide clearly is mixed among trustees, making it that much harder for them to convert the dubious. Malaney notes that among his 13-member board, "two or three are 100 percent opposed, one or two are totally in favor, and everybody else supports coverage for all but thinks the way the law pays for it is irresponsible."

As a member of the American Hospital Association board of trustees, Malaney urges those critical of the reform law to see it in the context of the core principles outlined in the AHA's Health For Life model, which contends that responsible reform must incorporate: a focus on wellness; health coverage for all, paid for by all; the highest quality and most efficient and affordable care; and the best information.

AHA President and CEO Richard Umbdenstock says the trustee audiences he's spoken to recently have "been so focused on the bill that they appreciate being reminded that there have been some real fundamental changes under way for some time." The concepts of integration, linking payments to outcomes, striving to reduce readmissions and other factors have been gaining ground for the past few years, and in many cases the law merely accelerates their adoption.

"The real points of contention were not so much over delivery system and payment reform or transparency, but over coverage and financing," Umbdenstock says. He adds, the questions trustees should ask decision-makers are: "What's the price of that [political] pushback in terms of people not covered? What's the price in terms of changes not made to the system that could lead to greater efficiency? What's the price of not knowing what procedures work better in various circumstances? Any delay or reversal is going to come at a price."

When advising trustees on reform outreach, Richard de Filippi, a trustee for Cambridge Health Alliance in Massachusetts and immediate past chairman of the AHA, says he looks beyond what might get "tinkered with or delayed," to the initiatives trustees can pursue immediately.

For instance, he says trustees can play an invaluable role in promoting greater care coordination among providers as accountable care and bundled payments take hold. They also can help develop community-based initiatives to address socioeconomic factors that lead to readmissions and care disparities for which hospitals will be penalized financially.

"The whole push toward wellness will be the only way to avoid these," de Filippi says, adding that the focus on "wellness and prevention in the community will have to come out of a board of trustees. Hospitals don't really do that now. It's such a fundamental shift in our mission that if it doesn't come from the top down, it won't work."