SEATTLE — Although most state officials have a love-hate relationship with the Patient Protection and Affordable Care Act, that is not stopping health policymakers from using it to further their own goals, speakers said at last week's State Health Policy Conference of the National Academy for State Health Policy.

"I don't think the ACA or the Supreme Court decision catalyzed the states," said Patricia Boozang, managing director of the law firm of Manatt, Phelps & Phillips, which advises states on health policy.  "But they did catalyze new thinking." Linda Sheppard, special counsel and director of health care policy and analysis for the Kansas Insurance Department, said, "The ACA just pushed the boulder over the cliff." The states, she said, were already working on most of the initiatives contained in the ACA.

Alan Weil, NASHP's executive director, observed that the boulder image was "interesting, especially if you are in the boulder's path."

Medicaid seems to be the program most squarely in the boulder's way. Although not all states plan to expand Medicaid, most appear to be trying to transform it. Several themes emerged at the meeting around efforts to move the mountain that is Medicaid.

One was using the program's purchasing power to reshape care delivery. Julie Weinberg, director of the New Mexico human services department's medical assistance division, said that the state chose to expand Medicaid, although the governor has warned that if federal funds dry up, "this will be the first program to go." The state is pursuing further use of managed care and paying providers differently in order to change the behavior of hospitals, she said. With an expected Medicaid population of 700,000 out of an overall population of 2 million, New Mexico should be able to flex its muscles as a purchaser. The state also is adjusting the benefit package to include services that are needed by low-income childless adults, whom "the program was never designed for," Weinberg observed, including dental care and substance abuse treatment.

Another theme was alignment of processes, services and data. But getting varied state government entities, providers, insurers, and the public on the same page is easier said than done. José Montero, director of the division of public health services in the New Hampshire Department of Health and Human Services, lamented that different state government entities "speak different languages," and it is difficult to get them all to use the same tools. That goes double for payers and providers. Nonetheless, many state officials gathered here envision seamless systems in the future, where people do not "churn" on and off Medicaid, the program is integrated into insurance marketplaces, and all information on costs and utilization is aggregated in one data base.

A third theme was ensuring that newly covered people know how to use the system. Nora Leibowitz, chief policy officer for Cover Oregon, the state's insurance marketplace/exchange, warned: "It's fine to give people coverage, but that's not enough." Also needed is education on how to use insurance, manage one's own health and care, and negotiate a new landscape where medical homes will replace non-emergency use of the hospital emergency department.

Obviously, the states are enjoying their traditional role as "laboratories" in these changing times.

Tomorrow's report from the NASHP annual meeting looks at how states are experimenting with Medicaid waivers to further expand coverage.