Molly Droge, MD, FAAP

The health reform legislation passed by Congress is expected to usher in a new age in health care in the U.S., but it will also trigger incredible change and uncertainty.

Those uncertainties will be the focus of an NCE plenary session, "American Health Care at a Crossroads: Implications of Health Reform to States" (P2057), to be presented October 3.

"The states are still in trouble with the recession. They are having difficulty with budget gaps, and now this just throws another huge wrench into the mix. It's a good wrench for people who need health insurance, but it is going to be challenging to get this to work at the state level," said Molly Droge, MD, FAAP.

"New bureaucracies, like health insurance exchanges and temporary high-risk pools, will be required," said Dr. Droge, chair of the AAP Committee on State Government Affairs. "Changing attitudes is also going to be a big part of it — the attitude that all people deserve care and that we need to get them into a system that works. It is not going to be easy to do that."

The historic legislation is only a piece of the new health-care puzzle. In the coming months, federal agencies will be writing rules to create new processes and implement new systems, she said. Then, states will have the challenges to make those processes and systems work.

"Many of the state agencies are going to be scrambling to figure out how systems are going to work in the different states. Each Medicaid program is state-run and state-based, so they are all a little different," Dr. Droge said. "One recipe is not going to cover everybody."

The reform legislation requires states to support Medicaid and Children's Health Insurance Plan (CHIP) funding and programs at their current levels, but many states have been slashing those programs to avoid huge budget deficits. With the "maintenance of effort" requirement, those state cuts will not be allowed if they have not already been incorporated into the states' Medicaid and CHIP programs, she said.

Federal funding will be available to help states with multiple projects, like expanding Medicaid programs to care for the poorest, uninsured citizens; setting up temporary high-risk pools to help those with pre-existing conditions who cannot get insurance; and creating health insurance exchanges to provide families with standardized information and easy-to-compare choices to decide which health insurance option works for them, Dr. Droge said.

Despite that support, more than a dozen states are threatening to file lawsuits to challenge the constitutionality of the reform legislation, even though those challenges are expected to fail. It all means a battle is brewing. But once people understand how health reform changes improve their health insurance, coverage and access to care, they may wonder why states are fighting these reforms, she said.

"For us, as child advocates, it is important to monitor what is going in our states," Dr. Droge said. "Pediatricians need to understand health reform and remain vigilant about the challenges to reform. We need to educate the public and families about reform, and it is important to participate in the implementation efforts of health reform at the state level.  We must continue to speak up for children and their families."

The health reform legislation, like Social Security and Medicare before it, will have to evolve to solve problems that are sure to arise, and pediatricians must be involved in that process, she said.

"It's a very complicated Rubik's cube. Everything that happens affects other things; there are multiple moving parts," Dr. Droge said. "It is going to be very interesting to see how it comes to pass. Health reform has passed on the federal level, but now much of the action is going to be focused on the state level. Unfortunately, our states are not in good fiscal shape to take on huge new projects that have definite timelines.

"This is not the final word. It is going to change a lot. It's not unusual to have this overwhelming sense of ‘How are we going to do all that?'"