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NACo News Updates
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About NACo – The Voice of America’s Counties
National Association of Counties (NACo) is the only national organization that represents county governments in the U.S. NACo provides essential services to the nation’s 3,068 counties. NACo advances issues with a unified voice before the federal government, improves the public’s understanding of county government, assists counties in finding and sharing innovative solutions through education and research and provides value-added services to save counties and taxpayers money.
Counties’ role in health care likely to be impacted by Trump Administration Paul Ryan’s health care restructuring proposal would mean per capita cap or block grant for Medicaid
By Brian Bowden
One of the promises President-elect Trump made to his supporters was to repeal and replace the Affordable Care Act (ACA), or Obamacare. Congressional Republicans have also made Obamacare a target for repeal and have proposed significant changes to other federal health care programs.
What might this mean for county governments, which play a pivotal role in caring for America’s low-income residents, especially serving as the safety net for those who are unable to afford medical care?
Historically, most states have required counties to provide health care for low-income, uninsured or underinsured residents — care that is often not reimbursed. An Urban Institute study estimated that states and localities spent $20 billion on uncompensated care in 2013.
Meanwhile, counties invest $83 billion annually in community health systems and support 976 hospitals, 714 longterm care facilities, 750 behavioral health authorities and more than 1,900 local public health departments.
The federal entitlement program known as Medicaid is the largest source of health coverage in the country, covering approximately 75 million individuals.
Established in 1965, Medicaid is federal-state-local partnership that provides health insurance coverage to low-income children and their families, seniors and people with disabilities. Unlike Medicare, which is financed and administered by the federal government, Medicaid is jointly financed by the federal government and the states, with local governments’ support in many states. Counties contribute to the program in 26 states, and in the latest year in which data is available, local governments contributed approximately $28 billion to the program.
The ACA expanded Medicaid. States were offered the option to expand the population served by the Medicaid program to include low-income adults without children.
Thirty-two states and the District of Columbia exercised that option to expand coverage beyond families, children, pregnant women, the elderly and the disabled. Medicaid reduces the amount of uncompensated care that must be provided by county health systems, easing the strain on county budgets.
Yet the Medicaid expansion is likely the most vulnerable provision of the ACA under a Trump Administration and a Republican Congress.
In June, House Speaker Paul Ryan and the House Republican Task Force on Health Care Reform unveiled a white paper describing a vision to restructure America’s health care system as a part of Ryan’s A Better Way Campaign. If enacted, the proposal would withdraw the states’ option to expand the Medicaid program and would require them to accept either a new Medicaid per-capita cap allotment or a block grant.
Under this plan, beginning in 2019, each state would receive a fixed limit of federal funding for four categories of beneficiaries – the aged, disabled, adults, and children — amounts based on 2016 averages. Funding would be adjusted for inflation, which typically rises slower than health care costs.
States opting out of a per capita cap could receive a block grant, which would have a similar effect. As health care costs inevitably exceed the amount allotted by the federal government, states and counties would be left the bear the burden.
“Counties are very concerned about the risks of changing the structure of Medicaid from an open-ended, federal-statelocal partnership to a new cap or block grant model,” said Fulton County, Ga., Commissioner Joan Garner, chair of NACo’s health policy steering committee.
In the upcoming weeks, President-elect Trump and the incoming Administration and Congress will need to determine just how they will change the health care system to follow through on their promises to undo the ACA. In that process, counties must ensure that the federal-statelocal partnership is respected and financial burdens are not simply shifted to counties. As the public’s attention will be placed on Washington and states, counties must work with their members of Congress to remind them that all health is local. Impending changes in the nation’s complex health care system must take into account the role of counties.
Brian Bowden serves as NACo’s Associate Legislative Director for Health and staffs NACo’s Health Steering Committee, lobbying Congress and the Administration on all health issues impacting counties including Medicaid, behavioral health, public health, jail health and long-term care.
911
side group should come in and bring all the stakeholders together to talk about reforming the system.
One subject that should be studied and reviewed is how many PSAPs are adequate for Arkansas. There are 132 PSAPs in Arkansas. Is that too many? The County Judges Association of Arkansas voted earlier this year to support a bill that places a moratorium on new PSAPs. This is a bill the judges will propose in the upcoming session to coincide with a study of our 911 system.
Technology is another issue. The governor and the legislature are always looking for ways to increase technology to improve inefficiencies and to save money. I can get on my phone right now, push a button and have an Uber car pick me up within a few minutes. I wouldn’t have to give my location and the driver would know exactly where I was from the technology on my smart phone. If Uber can find you that easily, then why can’t 911? People can argue that Uber is only in the highly populated areas of the state, and there isn’t a demand for it statewide. That’s a fair argument, but there is a high demand for 911 services statewide. If Uber can use this technology in downtown Little Rock why can’t 911 use something like this to better serve Arkansans all across the state.
Next Generation 911 (NG911) is an Internet Protocol (IP)-based system that allows digital information (e.g., voice, photos, videos, text messages) to flow seamlessly from the public, through the 911 network, and on to emergency responders. This is technology that will improve communication and save lives because of faster response times. Is Arkansas ready for this technology? Another topic the outside consultant should look at is training for dispatchers. The turnover rate for 911 dispatchers in Arkansas is one of the highest in the country. What can we do to minimize the turnover rate?
The news normally opens the show with “good evening,” and then tells you everything wrong with the world. In this day and time, law enforcement has to be perfect with every decision they make. The media likes to point out when one law enforcement officer makes one mistake, and it’s magnified. 911 is far from perfect, but there are places in the state that come very close, and the rest of the state can learn from them. Citizens in Calhoun County deserve the same service as those in Benton County. Obviously the response time cannot be the same for all Arkansans because not everyone is the same distance from a fire station or a hospital. One thing that should be consistent is the reaction time. When you pick up the phone and dial 911, the fire truck or the ambulance should leave its post around the same time whether you make the call from Benton County or Calhoun County.
Going into the 91st General Assembly, every legislator has heard many wants and/or needs from multiple constituencies. So how does the legislature maneuver these needs and how important is 911? Many people believe public safety is the No. 1 job incumbent on our government. This legislature supports our men and women in uniform and the job they do to keep us safe each day. If you ask an officer what is the most important tool they use, just about all of them say communication. That starts as soon as someone dials those three digits.
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