Ilisa Halpern Paul, a health care lobbyist and head of government relations at Drinker Biddle & Reath, is a native Californian. Her deputy, Jodie Curtis, is from Wisconsin, and fellow lobbyist Jeremy Scott is from Ohio.

Last week’s re-election of President Barack Obama — and with it, the confirmation that the Patient Protection and Affordable Care Act is here to stay — is prompting the three of them to become self-taught experts on their home states’ politics and major policymaking players. That's because the federal health care law requires states to build online marketplaces, called health insurance exchanges, where uninsured people can comparison-shop for plans. The makeup of those exchanges has yet to be determined — states face a Nov. 16 deadline to decide whether they’ll build their own or leave it up to the federal government — and many health care lobbyists are shifting their attention from federal agencies and Capitol Hill to the 50 state legislatures that will be calling the shots on their respective exchanges.

“In the next couple months, we’re going to start putting together mini-
strategic plans for additional state outreach,” Paul said. “A natural place to start is with our team members’ connections to their home states. In the first year, we won’t be able to cover all 50 states, but we identified the need for us to start rolling up our sleeves and getting better versed in state legislative activity.”

When states begin building exchanges, Paul’s group wants to be in position to help clients shape what those exchanges will look like. Health care providers, for example, stand to gain additional patients through the exchange, and will want to be included in insurers’ preferred provider networks. And patient advocacy groups will be lobbying to ensure that exchanges provide access to certain kinds of patient care or therapies.

“Most of the law and lobbying firms in D.C. are very D.C.-focused,” Paul said. “For states choosing to set up their own exchanges, it’s going to be a very state-driven process. For a firm like ours, if you’re able to translate your work to the state level, you’re going to be competitive. Otherwise, large law and lobby firms will lose business to state-level lobbyists and boutique shops.”

Stepping up networking

Drinker Biddle’s lobbying group, which specializes in health care, made a strategic decision six months ago to network more with staffers and advisers to state lawmakers. The firm sent lobbyists this year to meetings held by the National Conference of State Legislatures, and will be sending several lobbyists to the annual meeting of the National Association of Insurance Commissioners this month.

Only 14 states are aggressively moving ahead to have their own exchanges up and running by the 2014 deadline. But there will still be a lot of work for lobbyists in states that are leaving exchanges up to the federal government.

“If you’re representing a client in a state that decides to implement a health care exchange, the lobbying strategy around that looks very different than if you’re representing a client in a state that decides to let the [feds] implement a federal exchange,” said Robert Bradner, a health care attorney and lobbyist at Holland & Knight, who represents hospitals and insurance companies. “In the first case, you’re going to have lots of decision-making in state capitals. In the second case, you’re going to have to engage in a more complicated approach to the federal government.”

And the exchanges are just one component of the Affordable Care Act that will keep health care experts busy for years to come. One part of the law — the 2.3 percent tax on medical device makers — is in limbo, opening the door for a lobbying battle to determine its future.

Many hospitals, health systems and insurance companies that were waiting to see whether the law would go forward must now comply with a bevy of other regulations — including some that are missing key details that the Labor, Treasury and Health and Human Services departments will have to fill in.

Some of those include: What exactly does an employer have to provide employees to avoid paying a penalty? What “essential health benefits” do plans have to cover? What is the definition of part-time employee, since the law only requires employers to provide coverage to full-time employees? How will Medicaid expansion be implemented?

“From an advocacy point of view, this continues to be what I call ‘three-dimensional chess,’” Bradner said. “You’ve got to look at what’s going on at the state level with respect to Medicaid and the exchanges. You’ve got to look at what the administration is doing as they’ll be filling in the blank spots in their regulatory scheme. And you also have to look at Congress in several respects, to work with members of Congress to provide input.”