[author: Shari Gross]
When I sat for my first conference on the Patient Protection and Affordable Care Act (“ACA”) in 2010, one thing was clear: Nothing. The expert presenters all admitted, with sympathy from the listening audience, that they had not (and could not) read the ACA in its entirety. They were afflicted with the same problems that we all were: A void of specific information about the ACA, a handful of known changes to be enacted in the future, and a general sense that an enormous transformation was about to occur in health care in America. Since then, the information vacuum has begun to fill in slowly. We know that the ACA is intended to improve access to health care, improve quality, and cut costs. We know some of the mechanisms that will be used to accomplish these things: Insurance exchanges, the health insurance mandate, Accountable Care Organizations, and electronic medical records. Since my first glimpse in 2010, it seems the ACA has made it onto every health care related conference and association meeting agenda, and has been the subject of discourse in trade publications and newsletters. Good. We need to be talking about it and learning about it.
My professional perspective on health care comes from the public sector. Since the ‘80s, I have worked in community behavioral health. I have worked within institutions and within hospital settings. I have managed the operations of non-profits and government. I have operated county-administered human services programs reaching out to families dealing with everything from chronic behavioral health conditions to substance abuse to child dependency issues. I watched “Managed Care” evolve nationally and in Pennsylvania, my home state. Now, I see that we are poised again for a big systemic transformation and, as with Managed Care, it is hard not to be focused on the vacuum of information about the details. In the face of its enigmatic enormity, it is easy to make assumptions that the ACA not only changes everything, but that we will be so caught in its tow that we will have no ability on a personal, organizational or systemic level to go beyond the ACA to craft a health care model that is as dynamic and functional as we need it to be. It is common to detect a collective helplessness amongst health care providers—and consumers—and an expectation that we are all waiting for the ACA to fully reveal itself in all its operational glory so that we know what our lives will be like.
Systemic policy directives with the scope of public managed care programs and the ACA make profound and far-reaching changes in the way we give and receive health care, there is no doubt. And while government at the federal and state levels ultimately dictates how Medicare, Medicaid and other grant funds will be used for health care, I believe there remains an opportunity for local policy makers, health care providers, consumers, and others in the health care industry to shape and add depth to the framework of these historic structural changes. Many decisions are yet to be made in Pennsylvania and other states regarding the roll-out of the ACA, and for that matter, the continued operation of state Medicaid programs that provide support to people with behavioral health, aging, physical health and developmental disability concerns. Far from being a “done deal,” now is the perfect time to inform and influence policy makers at every level about the needs of the most vulnerable people within our communities. With regard to Pennsylvania specifically, the role of local government in customizing health care systems is an opportunity that cannot be overlooked as the ACA approaches.
Pennsylvania is a large commonwealth with great diversity and distance from one corner to the other. The role of counties as a way to bring organization, administer state and federal programs, and meet local needs is critical. When the Commonwealth implements major programs giving counties the “right of first opportunity” on managing Medicaid programs or other health care initiatives, it ensures that counties will take responsibility for assessing local strengths and weaknesses with regard to health care issues. This gives communities an opportunity to craft systems around these initiatives that more closely meet local needs, rather than having to accept a one-size-fits-all solution. Why is this important?
Cultural relevancy is only one reason, and it provides a helpful illustration. Many years ago, I participated in a lecture on cultural competency and mental health, given by a mid-level official of the Commonwealth. During his talk, he emphasized how important it was for every county in Pennsylvania to customize mental health programs for the Amish. Certainly, “Pennsylvania” and “Amish” are closely linked in everyone’s mind. But in my home community, a federal resettlement site for refugees from all over the globe, we had greater and immediate needs to accommodate the Somali, Nepali, Ukrainians and others who appear in much larger numbers within our city than the few Amish citizens who live on the edges of our county. The speaker’s emphasis on meeting the needs of the Amish certainly hit home for many of the listeners in the audience, none of whom were scrambling to find Somali interpreters or struggling to understand the culture and trauma of the people newly introduced to my home community. And while we in Erie greet thousands of refugees from war-torn areas of the earth, three hours to the south of us a primary concern is accommodating the mountain culture of the Appalachians. I use cultural competency as one example as to why our size and diversity in Pennsylvania should spur a state-wide call for local customization of government-sponsored care systems. There is no real way for the Commonwealth, or the federal government for that matter, to effectively craft access protocols and care delivery systems that make sense when you consider the cultural diversity and even economic and geographical differences within Pennsylvania. That is a job best left to the locals, and it is up to the locals to advocate to the policy makers to allow for this type of customization at the community level.
Why might communities want to advocate to locally customize government sponsored systems of care, aside from cultural and geographic relevancy?
Local control or influence over resources fosters local ability to solve problems: Communities are dealing with diminishing resources and mandates that make the job of serving the most vulnerable citizens very difficult. Community members are better informed and have a better historical perspective on their own friends and neighbors than a remote entity, and this intelligence combined with ultimate influence over care dollars may permit communities to solve difficult and costly crises among outliers within the membership.
Economic development: Local care and care management systems produce jobs locally. Wherever possible, communities must look to their own local capacity to be involved in health care management. The loss of these dollars and jobs to remote organizations can be catastrophic to a community, and yet human services and health care are often overlooked by local elected officials as opportunities for economic development.
Customizing the benefit plan to reflect special needs: Specialty health care needs, such as behavioral health, can be emphasized within the health plan. Benefits can be expanded to include non-treatment or less traditional public program strategies that promote stability and recovery, tailored to the needs of the community.
Creating advantage through cross-system partnerships: The health needs of the general public are reflected within the services and activities of many government systems. Often, people and entire families are involved with multiple systems such as mental health, drug and alcohol, physical health, etc. To avoid duplication of service and to muster the most effective use of resources, partnerships at the local level across these systems are critical. The impetus for this coordination and even integration must be locally driven, and can be imbedded in policies regarding management of local resource and health care dollars.
Local influence or local control does not mean that county government should set up shop to manage care or to become an accountable care organization. Not every county would find that to be possible or desirable. But having the first right of opportunity does permit local government to determine the appropriate depth for its own involvement in care systems, matching the initiative at hand to infrastructure that already exists. It permits local government to look for opportunities to create efficiencies where care delivery from different systems (mental health, developmental disabilities, child dependency, etc.) touches the very same persons and families over and over again. These efficiencies are good for the taxpayer, but ultimately best for the individuals receiving the care—and are typically a relief to the providers as well. It also fosters the possibility that effective public-private partnerships will be formed, as communities look for ways to fill gaps in expertise, technology, resources and necessary infrastructure. When a community partners with an experienced health management organization to create a system of care—crafting it to reflect community values, needs and goals—great things result. Now is an excellent time for local policy makers, elected officials, health care providers and health management entities to join together to promote effective local models as the federal and state governments seek to roll out the ACA, or as they seek to modify existing public health care programs. We all hold an important piece of the intelligence necessary to implement such large initiatives effectively, and only through our insistence will we ensure the best results for our own communities.
Shari Gross is a consultant and author who most recently served as the Director of the Erie County Department of Human Services in Erie, Pennsylvania. She has worked in government, community- and hospital-based nonprofit organizations for the past 30 years and specializes in health care and human services administration. She has served on state-wide boards and councils dedicated to the provision of services to persons with disabilities and healthcare concerns. Ms. Gross earned her Master’s degree in Clinical Psychology from Edinboro University in Pennsylvania.