The Patient Protection and Affordable Care Act mandates that U.S. residents obtain health care coverage through their employer; with Medicare, Medicaid or other federal programs; or by purchasing it through state-based health benefit exchanges.
The hallmark of the ACA is simple: enrolling as many of the estimated 32 million individuals without coverage into the health care system as possible. But the administrative burden of coordinating health insurance plans and enrolling those newly eligible for insurance is daunting.
The solution is to join with an often forgotten partner in the nation's health care delivery system: local governments. While much of the discussion about the ACA has been at the federal and state levels, local governments have experience in enrolling the uninsured in federal programs. Health care organizations and local governments can join forces to respond to the ACA's requirements.
Obtaining Coverage for the Uninsured
The ACA emphasizes primary care services and includes incentives, in the form of increased reimbursement rates, for private providers who serve Medicaid patients. However, for providers to benefit from higher fee reimbursements and related incentives, patients first must be enrolled in Medicaid. This is where key opportunities for innovative public-private partnerships lie.
Primary care providers can learn from local governments' efforts in two ways:
Emulating their enrollment methods. Providers can tap into the methods local governments have created to increase enrollment; many local governments have gained invaluable knowledge regarding how people enroll and how they can access health services under various federal programs. These experiences will provide invaluable lessons to providers in terms of what practices work and what practices do not work.
Using community-based alternatives to technology. Given the ACA's "no wrong door" policy and the potential for issues arising from different self-service electronic enrollment systems, some stakeholders have recommended that states maintain community-based enrollment assistance as part of the online enrollment system. This assistance requires a deep understanding of the existing community-based organizations participating in health care delivery to residents.
Many of these CBOs receive financial support from local governments for the delivery of services; and local governments, like counties, often play the role of a community facilitator in convening collaboration efforts across CBOs that at times view each other as competitors in local health care delivery services. Thus, any community-based enrollment system must rely on local governments to ensure effectiveness, given the unique role local governments can play in bringing people together to work toward a common good.
In fact, some stakeholders have recommended that states design exchanges to allow for enrollment at multiple local entry points, including government offices, hospitals and health care sites, and other neighborhood locations, which are more readily accessible by certain portions of the population, such as those communities where access to technology is an issue due to income levels and related technology-related infrastructure gaps.
By the same token, local governments can learn from private providers' efforts in two ways:
Emulating private marketing efforts. Providers that have developed innovative marketing tools to attract patients can share their marketing strategies with local governments to improve local public education efforts and increase enrollment. For example, providers can collaborate with local governments to secure grants designed to promote public education about and enrollment in exchanges under the ACA's "navigator" programs.
Using technology know-how. Some stakeholders have described exchanges as being a "cross between Amazon and Expedia" for health insurance, and have questioned whether any government agency can work like Amazon.com or similar websites. But providers can bring their technology expertise to ensure that enrollment efforts are efficient. Providers also can ensure that any exchange websites are easy to use and trusted by users, so that both public and private insurance options are understood easily.
More Benefits to a Partnership
A strong partnership also can facilitate network development, professional training and health promotion.
Accountable care organizations. A key provision of the ACA is to provide for the Medicare shared savings program by establishing accountable care organizations — networks of doctors and hospitals that share responsibility for patients' health. ACOs will be paid through a fee-for-service payment system, but providers will have a financial incentive to keep costs down and meet quality benchmarks.
Any effort to create ACOs undoubtedly must involve local governments, which often provide health care services where there are existing gaps in services. These local governments also often operate "safety net" hospitals and provide direct community grants to community-based organizations for health care service delivery. Again, the ability for a single entity — a local government — to convene a group of stakeholders for purposes of encouraging collaboration cannot be discounted. The ability of these local governments to build consensus across competing service providers is critical to any successful ACO effort. Leadership, especially under the ACA, in organizing health care delivery models is critical, and local governments can create the impetus for collaboration.
Training health care workers. The ACA includes various provisions relating to health workforce training programs, including reauthorizing the National Health Service Corps to provide scholarships and loan repayment assistance for medical professionals who serve for a specified number of years in a health professional shortage area. Local governments offer a number of workforce training programs in conjunction with the private sector. These partnerships could serve the expected increase in the number of patients.
Educating the public about healthy behaviors. Improving public health and wellness is a key aspect of the ACA, which gives health care providers incentives to provide efficient and high-quality services so that Medicare and Medicaid patients do not return for follow-up services. The ACA provides for this investment in prevention and public health programs through the creation of the Prevention and Public Health Fund, which will provide $15 billion over 10 years in mandatory funding. The focus of any public health initiative must be on a community-based approach using local community health workers to promote positive healthy behaviors, particularly in medically underserved areas. The role of local governments in public health education efforts is, therefore, critical.
The ACA creates tremendous opportunities for establishing a more effective and efficient health care system. Local governments cannot be forgotten by the private sector when seeking to create this system for millions more Americans.
Ash Pirayou, Esq., is co-chair of the Government Relations Practice Group and a partner at Rutan & Tucker LLP, Palo Alto, Calif.