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New Roles for States in Health Reform Implementation

In this Ask the Expert column, we talk with Ray Scheppach, executive director of the National Governors Association (NGA), about new roles for states in health reform implementation.

What are the first three concrete steps that states need to take to get organized for federal reform?

First, create a commission or team to oversee health reform implementation. Because of the scope of the health reform law, there are many stakeholders involved, and the action of multiple state agencies as well as state legislatures will be necessary. The commission should be the body responsible for disseminating information and decisions to appropriate agencies as the major decisions are made and implementation becomes the main focus.

Second, create a strategic plan. The commission should create a strategic plan, which outlines how the states will approach not only those changes in the law, but also the longer-term strategy for reforming the health care system—including cost containment, quality improvement, and more efficient delivery of care.

Third, conduct a needs assessment. It is important for states to conduct a needs assessment to evaluate where program gaps exist and what agencies may be best suited for new programs. It will also be critical for governors to identify where higher-level decisions need to be made and which state personnel will be charged with handling those issues, as well as where resources will be allocated.

As states develop implementation commissions and task forces, what "ingredients" for these groups will help them be effective?

There are two types of commissions or task forces that need to be developed, and states may establish either or both. The first is an internal working group of state officials from various agencies and offices, including the governor's office, the health policy department, the insurance department, the Medicaid agency, the public health department, as well as the office of tax and revenue and the budget office. These groups can ensure coordination across state agencies and determine the critical issues that should be decided by the governor's office.

The other type of task force that is crucial is a stakeholder group. It will be vital to bring those affected by health reform into a discussion to get their input and buy-in into state decisions early in the process. In addition, many of the groups that would likely be included have firsthand experience in key issues, such as eligibility and enrollment, systems infrastructure, and public outreach. Groups that would potentially be a part of a state's stakeholder task force include insurers, providers, brokers, legislators, consumer groups, as well as employers and unions.

How should these task forces/commissions be held accountable for successful implementation?

The governor's internal commission should communicate directly to the governor, ensuring that state implementation is coordinated and timely. This will be a difficult task due to the number of moving parts and the array of decisions that must be made by HHS over the coming months. The internal commission is a critical component of the success of reform implementation; however, there are many unforeseen issues that are likely to arise from implementation that the commission will have to take into consideration and revise plans accordingly.

The stakeholder task force should be charged with offering recommendations to the governor on reform implementation based on stakeholder experience and likely impact. While there are several issues in implementation, the task force should focus on the components with the most involvement by outside groups. This will get the most relevant and needed feedback, as well as potential cooperation for moving forward with implementation.

How can governors who are opposed to national reform still prepare their state for it?

Based on NGA's interactions with state officials, it is our understanding that most states are moving forward with implementation planning despite lawsuits and political opposition to the new law. Most governors realize that legal challenges may take years, and the near-term resolution of political differences is unlikely. In the meantime, many of the short-term reforms are going into effect and strategic planning needs to happen for the components that begin in 2014. I believe that most states realize the large scale of these reforms and recognize the importance of addressing them now, regardless of what happens in the future.

How can states best organize for reform in light of the tremendous state budget crises?

Until federal funding is available for planning and implementation, states are struggling to work with the resources they have, which due to the budget crisis are extremely limited. Few states have dedicated staff to exclusively work on reform implementation. Rather, states have reassigned employees or added to their responsibilities to handle the implementation issues and planning. Some states are working with local foundations to help with the cost of evaluating their current systems and the strategic planning necessary for health reform. Federal funding for implementation will be critical to help hire staff, develop comprehensive and coherent work plans, involve stakeholders, and ensure informed decisions.

How can state planners and policymakers learn from each other, and seek assistance with organizing for reform?

We encourage states to have a dialogue with each other, and learn from each other and from early adopter states. It's often efficient for states to adopt other states' programs. The more they can learn from each other, the less burdensome health reform implementation can be. That's why NGA has joined with three other organizations to create the State Consortium on Health Reform Implementation

Together with the National Association of Insurance Commissioners, the National Association of State Medicaid Directors, and the National Academy for State Health Policy, we are working to coordinate implementation efforts to ensure that states are getting relevant and timely information and have an opportunity to share experiences. The consortium provides a central place for the main state officials involved in reform implementation to ask for approaches and techniques for implementation, as well as hear from other states.

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