As the country sits through tireless efforts from the U.S. House of Representatives to repeal the already-ruled-constitutional Affordable Care Act, Bruce Dart, director of the Tulsa City-County Health Department, speaks a recurring phrase.
"We just don't know."
In the wake of the release of the Leavitt report, which called for an increased role for local health departments in the overall health care process in Oklahoma, Dart and company are waiting to learn just exactly what that would mean.
"I've seen the Leavitt report, but I don't really have the go-ahead to implement the plan yet," he said. However, that plan in question is the question.
"The biggest thing is what's going to happen in Congress," he said. "We know what the Affordable Care Act will do, as far as opening up individuals to getting the kind of preventative care that will keep them from getting sick."
And that's important, as preventative care represents a good chunk of what the health department does -- whether it's family planning, immunizations, or lifestyle management. However, the not knowing is the hard part.
"Before it rolls out, it needs to be in an iteration where we can use it," Dart said. "But at this point, we're not sure what that is."
There has been a great deal of talk surrounding the Affordable Care Act that deals with the home model, which basically involves a team of health care professionals all familiar with any given patient.
This, among other things, would cut down on unnecessary tests and other procedures that can contribute to exorbitant costs associated with health care. However, if the Affordable Care Act's implementation skews away from prevention and more toward primary health care, Dart said that could cause problems for local health departments, as prevention is a primary focus.
"There's supposed to be more funding for primary health care and a big focus on the home model," he said. But that would necessitate major changes in many aspects of the health department.
"Local health departments have always been viable as a safety net entity," he said. "But is that going to be our role in the future? It falls under the prevention mode -- our family planning, immunizations, and we're involved in some nationwide conversations about STDs being treated out of the clinic. It's all about prevention. Some of those things are funded by a combination of state and federal and local dollars. Right now, at one of our clinics, we partner with OSU for primary care. Is that something we're going to keep doing?"
As an example, Dart referenced chronic diseases, a focus of about 75 percent of the health department's workload.
"We know how we at the local level can get more involved in activity that will stop clients from either becoming victims of chronic disease or at least delay the onset through healthier living," he said.
But if the Affordable Care Act ends up taking the focus from preventative care and placing it on primary care, then there will be a whole lot of scrambling.
"We have a problem in Oklahoma," Dart said plainly. "We're 49th in the ratio of primary care providers to patients. So if everyone has insurance, we're not going to have enough primary care providers. We need more. We kind of have an inability to compete with other entities to assume greater roles in primary and preventative care."
But Dart and the rest of the health department aren't just sitting around wringing their hands.
"We're waiting, but we also want to be ready to go when it happens," he said. "We want to make sure we can provide these services."
So there are several ideas on Dart's drawing board, all in the name of being ready for the time when so-called Obamacare goes into full effect.
"I think we're better off to work on several scenarios," he said. "Things in Washington are going to happen at some point. We need to have several scenarios in place so that we can respond to it and not react to it. If we're reacting rather than responding, we're going to be really slow to stand up."
And again, he talked about not knowing what's coming. One gets the idea that it's really frustrating to be Bruce Dart these days.
"Take the Leavitt report," Dart said, referring to recommendations put together to guide the state on ways to help low-income, uninsured Oklahomans without embracing Medicaid expansion.
"If that's a scenario that plays out, are we prepared to stand up so that the recommendations in the Leavitt Report can be implemented? If Congress decides, 'We're not going to increase primary care, but focus on preventative care,' do we have to resources to do that? If we have several scenarios, I think we'll be able to have a plan to put into action, or commingle several of them. The hard part is not knowing," Dart said.
While the health department isn't completely flat-footed, the fact remains that preventative care is its focus -- so much so that there is only one facility offering what are essentially primary care treatments. That it looks very much like the home model helps, but still:
"We only do that in one location now, and it's staffed by physicians and nurse practitioners from OSU," Dart said. "If clients want to access other services in our building, like family planning, STDs, immunizations, then they can. We have a good home model here in the building. Is that model going to stand the test of time? We don't know."
The health department is looking at multiple scenarios for action going forward.
"We're not just waiting," he said. "We're looking at the structure we need to be able to implement when this finally happens."
He mentioned a friend of his who works for the health department in Missouri.
"He always says you either fail to plan or plan to fail," Dart said. "You plan and plan and plan, and you hope you're doing the right thing. But you can't just sit around. If we ramp up, even it's the wrong thing, we've got something in place that can allow us to be adaptable. That's really the key ingredient. If we're one thing at the health department, we're extremely adaptable."
So the planning goes forward, and while that's good, it often raises still more questions.
"Right now, we're talking about new services," Dart said. "We're still trying to figure things out -- new roles and things like that to consider -- but we can't waste our time on things that aren't going to happen. Are we going to have to realign our resources? We just don't know yet. Am I going to have to retrain my staff if the Affordable Care Act means we have to change the way we're doing things? I wish I had an answer to that, but I just don't."
Share this article: