Uncertainty. Of all the debate surrounding the Affordable Care Act, there’s little disagreement that healthcare reform is bringing with it a lot of questions — from whether it will be implemented intact to how it will affect local governments and their residents. Yet despite the uncertainty, many cities and counties have embraced their role as leaders in the community and are making sure they’re ready to help enroll and serve residents while determining what the ACA might mean for their own internal operations.

On Oct. 1, the exchanges — also referred to as marketplaces — opened for enrollment, the same day that a government shutdown went into effect due, in part, to debate surrounding funding for healthcare reform. Within the first week, some states began reporting enrollment numbers. On Oct. 5, Kentucky Gov. Steve Beshear’s office reported that more than 6,000 individuals and families had enrolled in coverage through kynect and that 186 small businesses had started applications for health insurance for employees. Maryland Health Connection announced that, as of Oct. 7, 13,500 people had created identity-verified accounts and that 326 residents had enrolled. The website had received more than 174,000 unique visitors and the call center had fielded 10,560 calls. In its first two days, Rhode Island had 366 people complete an application with payment finalized or pending. Throughout the first week, many exchange websites were warning visitors of temporary interruptions in service as improvements were being made.  

The catalyst for community action

Outreach is an essential component of the ACA and one on which local governments have focused. More than 47 million non-elderly Americans were uninsured last year, according to the Henry J. Kaiser Family Foundation (KFF). The majority were in low-income working families, with individuals living in the South and West being the most likely to be uninsured. The ACA’s success depends largely on cities’ and counties’ involvement in helping enroll residents without access to the internet, with language barriers, and those who don’t want to complete forms or are afraid to provide the information necessary to determine their coverage eligibility.

On Sept. 20, King County, Wash., launched an effort to enroll its estimated 180,000 uninsured residents who will be newly eligible for coverage. As part of the actions, Public Health - Seattle & King County is serving as the lead organization for the state’s In-Person Assister program and has trained 500 people competent in 34 languages to work with residents face to face. County Executive Dow Constantine also is enlisting every county department that interacts with the public — including parks, transportation and the assessor — to encourage residents to go through the screening process and sign up for a program based on eligibility. “The county and the health department need to play a critical role, so we have mobilized resources, but many city and county departments can help on a day-to-day basis,” says David Fleming, director and health officer for Public Health - Seattle & King County. To engage hard-to-reach populations, the department has created a network of 23 community organizations, such as the Seattle Indian Health Board and Asian Counseling and Referral Service. “If it’s going to work, it has to work in the community,” Fleming says. “We are the catalyst for community action.”

Taking a similar approach, Sonoma County, Calif., has hired 54 people that have been going through training for four to five months to help provide accurate information to residents. “It’s not OK to have people call a number at the state,” says County Supervisor Susan Gorin. “It’s important that we have a central role in helping people become eligible.” The county has an estimated 70,000 uninsured; of those, approximately 18,000 will be eligible for Medi-Cal, 21,000 for tax subsidies under the exchange, and 11,000 for coverage through Covered California, the state-run marketplace. Aside from helping people enroll in the exchange, Gorin says the county will be a one-stop shop for determining other services for which residents might be eligible.
Many of the outreach efforts are being focused on the homeless, chronic users of emergency rooms, and people with behavioral and mental health issues. But there’s a group crucial to the success of exchanges that could prove a challenge: the “young invincibles.”

“Cities are concerned about how they are going to get the Millenials to sign up — the younger people who will be eligible but don’t believe they will ever get sick,” says Neil Bomberg, program director for the Washington-based National League of Cities. “The more young people that sign up, the lower the cost will be for older people.”

In 2011, 22.6 percent of residents age 18 to 24 did not have health insurance, nor did 22.8 percent of residents age 25 to 34, according to the US Census Bureau, American Community Survey. In contrast, 15.3 percent of 35- to 44-year-olds were uninsured.

Campaigns have begun to reach uninsured youth. One, a TV ad for the Washington Healthplanfinder (http://wahealthplanfinder.org), shows a snowboarder taking a rough tumble and advises residents not to gamble with their health. Locally, King County is focusing more on social media to reach its younger population and has enlisted students from the University of Washington School of Public Health and community colleges to reach out to their peers.

Getting residents in general to enroll could be more difficult in states that have chosen not to expand Medicaid or that have opted not to create a state-run exchange and defaulted to a federally run exchange. “It’s very confusing to hear that Texas isn’t opting into a Medicaid expansion but that the Affordable Care Act is being implemented,” says Stephanie Taylor, public information officer for the Northeast Texas Public Health District. “We get a lot of questions about that.” (The state also has defaulted to a federally run exchange.)

According to a Pew Research Center/USA Today study conducted between Sept. 4 and 8, only 51 percent of respondents said that a healthcare exchange would be available in their state. Awareness of the exchanges was higher in states with a state-run marketplace (59 percent) versus those with a federally run one (44 percent).

The US Department of Health and Human Services has been trying to engage community stakeholders in states with a federally run exchange, while the non-profit Enroll America is focusing its efforts on those states as well. “Anecdotally, with a state-run exchange, they have a better chance of engaging from the ground up,” says Paul Beddoe, associate legislative director for Washington-based National Association of Counties (NACo). “And you have some state leadership that are actively trying to make it harder.”

Bringing together public health and healthcare

While many local health departments have focused on enrollment efforts, they also have many changes to prepare for down the road. This task is complicated by the uncertainty surrounding how many currently uninsured residents will end up obtaining insurance and what types of services they will be seeking. “Every health department needs to look at their community needs,” says Bruce Dart, past president of the Washington-based National Association of County and City Health Officials (NACCHO) and health director for the Tulsa City-County Health Department. His department, for instance, offers preventative — but not clinical — services. At the same time, Oklahoma is 49th in primary care provider to patient ratio. To provide primary care at one of the regional health centers, the health department has co-located with a provider from the Oklahoma State University medical system.

Sonoma County Board of Supervisors has invested in community health centers and sister organizations to improve access to care for residents, but also to help them expand capacity and services under the ACA. The Department of Health Services was awarded $3.5 million in funding under the ACA Community Transformation Grant program for community health and prevention activities. The county has invested in health centers, including $100,000 for West County Health Centers to expand its physical plant and the activities they are prepared to offer. “We need to understand the magnitude of where we want to go and how much work we need to do,” Gorin says.

For Hennepin County, its projections are focused on what will happen with its indigent care bill, says County Commissioner Mike Opat. Hennepin County Medical Center, owned by the county, is responsible for uncompensated care. The county reimburses $25 million to $35 million annually. “People ask: ‘Shouldn’t that cost go down now that there is healthcare reform?’,” Opat says. He points out, however, that some people think they are going to enroll in the exchange and have high-deductible plans with a high deductible they cannot pay. “Now we’ll have to try to collect the first $1,500 or $2,000,” he says. “I see that as a big unknown.”  

Other opportunities are available to local health departments under the ACA. An IRS mandate under the act requires non-profit hospitals to conduct a community health needs assessment every three years and adopt a strategy for meeting the needs identified. NACCHO has been encouraging local health departments to collaborate with local hospitals in these assessments and other planning. The Tulsa Health Department, for instance, conducted a community needs assessment for itself and two non-profit health systems. The systems used the assessment data and parts of the health department’s Community Health Improvement Plan to develop their own plans and meet the IRS requirements under the ACA. “We’re really pleased with the relationships that we have developed,” Dart says. “There is great potential for working together in the future. The ACA is all about bringing together public health and healthcare.”

Health departments also can provide direct services to become in-network providers under the ACA and bill for certain services, such as immunizations. But getting into that business is proving difficult for some. “People think that many agencies like mine will be looking for ways to bill for services that we haven’t in the past,” says George Roberts, executive director of the Northeast Texas Public Health District. “With immunizations, many don’t have the billing set up and aren’t already billing managed care companies and other insurance companies. They need to be getting into that business. It represents an opportunity to provide services to more members of the public.”

The health district has billed Medicare and Medicaid for years, but just recently started billing managed care companies, such as Aetna and Blue Cross and Blue Shield, for immunizations. “It’s been rather difficult because public health is different than a hospital or a doctor’s office so we’ve had to explain differences to the insurance companies.” Public Health - Seattle & King County provides a fair amount of direct services to people in the community and bills insurance, including Medicaid. According to Fleming, this means that some of the people they currently serve who don’t have insurance will have insurance to bill. The Tulsa Health Department doesn’t offer clinical services, but does have preventative services that it will be able to bill. It will be changing its financial system to have the infrastructure in place to begin billing.

Such good coverage?

Cities and counties are also employers, subject to mandate that employers with more than 50 employees provide insurance that meets certain criteria or pay a $3,000 per worker penalty. Bomberg says that some cities are worried — probably unnecessarily — about whether insurance plans they are providing will meet the ACA’s requirements. “Most cities and towns have such good coverage that they are not finding this to be an issue,” he says.

Yet one option available to local governments is to pay the penalty and have their employees seek coverage under the exchange. Or cash-strapped towns with less than 50 employees could do so without paying the fine. Those are both actions that Bomberg says he hasn’t heard many cities or towns considering. Milwaukee County Executive Chris Abele, however, has proposed eliminating health insurance coverage for employees as part of his 2014 budget and instead provide subsidies for them to purchase insurance coverage on the exchange.  

Others, including Detroit, Chicago and Sheboygan County, Wisc., are considering reducing retiree costs by transitioning some not yet eligible for Medicare off of city-provided healthcare into the exchanges. In Chicago, an agreement had been in place until June 20 requiring city-subsidized health insurance for retirees. Mayor Rahm Emanuel decided to extend the subsidy for six months and then start phasing it out for 30,000 retirees over the next three years. The retirees consequently filed a class action lawsuit against the city, arguing that the benefits are protected.

The excise tax — also being referred to as the “Cadillac tax” — goes into effect in 2018 and may affect still other communities. For plans whose value exceeds $10,200 for individuals, $27,500 for families or $11,850 for retirees, the amount exceeding the cap will be subject to a 40 percent tax to be paid by insurers. The upper limit will be increased for workers in high-risk professions and for employers with a disproportionate share of older employees or women. “Historically cities and towns and the public sector have tended to provide better benefits and lower salaries,” Bomberg says. “A fair number will have to confront the Cadillac tax and decide whether to keep their benefit structure in place and pay the tax or work with employees to lower healthcare packages to avoid the tax.”

Altering benefits may prove difficult because in many cases unions have negotiated better healthcare plans. Bomberg says he has received numerous calls on how to address this from cities that have collective bargaining approaching. New York Mayor Michael Bloomberg recently asked municipal unions to seek bids for the city’s health insurance to decrease premiums. Starting next year, Hennepin County is going to begin offering a new plan with lower employe premiums and perks that include three free co-pays per member and will continue encouraging employees to be more active. “We are going to take some risks with it,” Opat says.  

Some are hopeful that efforts to eliminate the Cadillac tax altogether will succeed. “At our annual conference, there was an interest in stopping the excise tax from going into effect,” Beddoe says. “There was concern that it could make it difficult to recruit and retain employees.” Bomberg believes that once the ACA has been in place a year or two, Congress will be in a better position to change some elements of the act, including the excise tax.

While Sonoma County is still evaluating its employee insurance plans, it is looking at the exchange as an opportunity for its employees who are uninsured. Gorin says they have been reaching out to employees who work part time for the county or minimally paid workers who can’t afford an insurance premium. (Under the ACA, full-time employment is defined as 30 or more hours per week.) “We are trying to help them understand their options under the ACA and for the first time the services they’ll be entitled to.”

Gaps in coverage?

Adding an element of uncertainty is the fact that states have been able to choose whether or not to expand Medicaid coverage to 133 percent of the federal poverty level (FPL) and whether to have a state-run, federally run or partnership exchange. As of Sept. 30, 24 states and Washington, D.C., were moving forward with Medicaid expansion; 26 states had either decided not to move forward or were still evaluating the option, according to KFF.

As of the same date, 16 states and Washington, D.C., had chosen to run their own exchange, 27 had defaulted to a federally facilitated marketplace and 7 had opted for a partnership marketplace. Only Idaho had declined to expand Medicaid, but will be operating a state-based exchange.

For states choosing not to expand coverage, this means that fewer uninsured people will be able to obtain coverage. “We’ve heard concern from states that aren’t expanding Medicaid about what happens when there is a big push to get people to sign up for coverage and there is nothing for them,” says Maeghan Gilmore, program director for NACo. “They don’t qualify for assistance under the exchange in states that aren’t expanding and the counties have safety net responsibility.”

In non-expansion states, local health departments and other stakeholders actively are looking for other ways to help the uninsured. Texas, for instance, has chosen not to expand its Medicaid coverage. “With not doing the expansion, I think we’re going to see some gaps in coverage,” Taylor says. “We are looking for other opportunities to expand coverage.” The Northeast Texas Public Health District, for example, submitted its soon-to-open Center for Healthy Living for Texas Medicaid Waiver 1115 funding. The center will allow people that remain uninsured to still have access to screenings, health management and education. In Wisconsin, which chose not to expand Medicaid, the University of Wisconsin Hospital and Clinics is donating $2 million to United Way of Dane County to pay for premiums for plans purchased on the marketplace. It will apply to residents with 100 percent to 133 percent of the FPL. Dart says that while Oklahoma isn’t expanding Medicaid, decision makers are coming together to find a way to expand healthcare for the uninsured. “Without that conversation, we might not be making sure as many people have access to care.”

Despite all of the uncertainty, some leaders within local government remain enthusiastic about what the ACA could bring. Constantine, for example, has been a champion for healthcare reform in King County and has initiated many of its outreach efforts. He expresses a common belief that when residents are uninsured it costs everyone more money. Yet he also sees the ACA as a way to encourage his region’s history of innovation and entrepreneurship. “We have some of the world’s leading businesses: Costco, Amazon and Microsoft,” he says. “A lot of people are held back from making a good idea real because they can’t afford to leave their jobs and their healthcare. By having this affordable care available, they can do what Americans do best, which is invent and create and take ideas and make them benefit society.”


Many organizations have dedicated considerable resources to helping local governments better understand and prepare for the Affordable Care Act. Here are a few places to go for answers to common questions and updates on what other states are doing. 

The National League of Cities (NLC) has put together the “Affordable Care Act Health Insurance Marketplace Outreach and Enrollment Toolkit for Elected Officials,” which is available at NLC.org. It provides an overview of the marketplace, sample outreach and enrollment plans, frequently asked questions, US Department of Health and Human Services director contact information by region and more. NLC also has a page dedicated to “Cities and the Affordable Care Act,” including a link to contact staff with questions about implementing the ACA.

The National Association of Counties (NACo) has a dedicated “Health Reform Implementation” page on its website at naco.org. The “Counties as Employers Health Reform Toolkit” covers the issues county leaders should consider before making any changes to benefit plans. “County Jails and the Affordable Care Act” looks at ways that counties can be involved in enrolling qualified individuals in county jails. “This has been a longstanding issue and the ACA provides an opportunity to address it,” says Maeghan Gilmore, the report’s author.

The National Association of County and City Health Officials’ ACA page at naccho.org includes links to the health reform webinar focused on the provisions relevant for public health. NACCHO collaborated with the National Association of Community Health Centers on the report “Partnerships Between Federally Qualified Health Centers and Local Health Departments for Engaging in the Development of a Community-based System of Care.”

The Urban Institute began a project in May 2011 that for several years will track the implementation of the ACA in Alabama, Colorado, Maryland, Michigan, Minnesota, New Mexico, New York, Oregon, Rhode Island and Virginia. One of the reports, “Insurer Participation and Competition in Health Insurance Exchanges,” was released in July and covers state actions to encourage or require participation in exchanges.

Health Affairs covers a number of ACA-related topics on its blog at healthaffairs.org/blog. One post, “Lessons From Early Medicaid Expansion Under the Affordable Care Act,” examines the experiences of six states that expanded Medicaid since 2010 and offers policy lessons gleaned from research and interview with Medicaid officials in those states.

For a roundup of news from the eve and opening day of the exchanges, kaiserhealthnews.org compiled “50 States, 50 Views of Health Exchanges,” that covers what states were doing to prepare for Oct. 1 and how they fared.