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State workers feeling major task of implementing health-care law

By Darryl Fears and Lena H. Sun
Wednesday, September 22, 2010; 12:42 AM

Even as President Obama prepares to acknowledge the six-month mark since he signed his health-care overhaul into law, the legislation remains something of a mystery for patients and politicians alike. Its impact is instead being felt largely by state workers nationwide whose job is to implement the law - and thus begin the mammoth task of transforming the care Americans receive.

For legions of men and women such as James Focht, who coordinates health information technology for the District, that means longer hours and extra work.

When Focht's alarm clock screeched at 3:45 one recent morning, he pulled himself out of bed in the dark, switched on a computer and started tapping out a proposal for a federal grant that would make it easier for hospitals, doctors and other providers to share electronic patient records. He hurried to finish his draft, take a shower and get to work at the D.C. Department of Health Care Finance by 8:15 a.m. so that other executives could edit the proposal and send to the Department of Health and Human Services by 5 p.m.

Then he began working on the next grant.

Focht and other bureaucrats in his D.C. office are quick to say that the health-care overhaul was worth the extra effort. But the task of expanding Medicaid to include millions more Americans, converting paper medical records to electronic records, and creating an entirely new health insurance marketplace is falling on state health agencies during a recession that has cut their budgets. And staffs - trimmed by layoffs, early retirements, furloughs and hiring freezes - are feeling the strain.

The federal government, meanwhile, is rushing to implement the law's major provisions by 2014. HHS has rolled out grant offerings worth more than $12 billion to help states with overhaul-related initiatives, such as establishing home-visitation programs to improve the well-being of children, increasing the number of primary-care professionals and planning to establish consumer insurance exchanges, a centerpiece of reform.

On Thursday, some of the law's earliest provisions will take effect, including allowing many children up to the age of 26 to remain on their parents' health insurance plans and forbidding plans to drop clients who become sick.

But applying for the grants isn't easy, and experts are starting to wonder if states with depleted budgets - such as California, Oklahoma and Virginia - can keep up with the conveyer belt of grant opportunities and account for millions of dollars once the money is awarded.

"Obviously, we have concerns that the federal government not just pass out money without knowing how it's going to be spent," said Diane Rowland, executive vice president of the Kaiser Family Foundation. "But it's a tricky balance of doing that and not overburdening agencies."

Alan Weil, executive director of the National Academy for State Health Policy, said implementing the overhaul is "a phenomenal task." Federal grants are the mother's milk of reform, he said, but added that he's not sure if there are enough workers to apply for them.

"Someone has to sit down and figure out things, write a strong proposal. What will we use the money for? What's our timeline? And this is all on top of what you normally do," Weil said. State health finance agencies, including the District's, usually manage Medicaid and Medicare services. The District and some states also manage public contracts to health-care providers that offer insurance to low-income residents who do not qualify for federal coverage.

HHS, the federal agency in charge of implementing reform, is not worried about whether states can handle the fast pace of the overhaul, said Paul Dioguardi, director of intergovernmental affairs.

"We've got great working relationships with the states," he said. "With the grant applications we've been putting out, we ask how can we make this as easy and streamlined as possible."

Cindi Jones, director of the Virginia Health Reform Initiative, has major concerns about whether employees can keep up. "We have less staff doing more," she said. "It's just difficult to pull somebody off their job to write grants. Second, when you do get grants, if you're successful, you have to have staff to manage it."

Jones likened the process to "a tennis court and everyone throwing balls at you. That's what it seems like."

The District and Maryland, where the overhaul is strongly embraced, have fared better than Virginia, where state leaders have criticized the law and sued to stop it. Yet the District and Maryland are also having to work hard to keep pace.

"There's a kind of gush, a great deal of activity," said Frances B. Phillips, Maryland's deputy secretary for public health. Some grants are formulas that require less effort, but others are "more competitive and require a tremendous amount of effort," she said.

Maryland won a $2.3 million grant to expand training for nurses and geriatric health at four state schools and received a $1 million grant for a home-visitation program for high-risk pregnant women, as part of the state's effort to reduce infant mortality.

In the District, the Department of Health Care Finance has about 20 fewer workers than normal and has only recently begun to bring in more people after a hiring freeze was lifted this summer. But Julie Hudman, the director, said implementing reform is a challenge that her staff is glad to handle.

At a weekly meeting on the first Tuesday of September, office executives discussed what they would do with a $1 million planning grant they were vying for. Focht wondered aloud which corporate group of consultants would compete for a contract to guide them on how to implement the city's insurance exchange. Hudman said the city should consider creating a regional pool shared by Virginia and Maryland that would allow residents of those states who work in the District to purchase insurance in the city.

Near the end of the meeting, Hudman reflected on the size of the job. Ten workers were hired away by HHS and the Centers for Medicare and Medicaid Services.

Said Linda Elam, the administrative director of health-care policy and planning: "We got hit hard, and no one is saying, 'Oh, you get a little more time to work this out.' I lost five people. I had two people in insurance eligibility; now I have one. She's here after 7:30 at night, working. She's doing both jobs."

Elam said she walked into her section and told her employees, "Some of you haven't been working on health-care reform stuff, but we're all working on it now. Pick out what you like. We're all going to have to pitch in."

After Focht, the health information technology coordinator, rushed to work with his grant proposal, one of the first people to see it was Chief of Staff Dianne Faup, who said she has read and edited grants over dinner "to smooth out the narrative."

A recent $1 million grant proposal to plan the city's insurance exchange "had people reading at night, and reading over the weekend to get that grant in shape."

"I don't know what real hours are anymore," she said. "We're on e-mails day and night. It's just become a lifestyle."

fearsd@washpost.com sunl@washpost.com

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