Throughout the implementation of the Patient Protection andAffordable Care Act, Americans have been treated to story afterstory detailing the landmark law's effect on a variety ofpeople.>>

There have been stories about cancer patients losing affordableplans and prescription coverage. There have been stories of brokersworking with clients to select new plans or discuss governmentsubsidies even though no commission is involved. There were storiesabout President Barack Obama symbolically signing up for healthinsurance according to the dictates of his signature domesticpolicy achievement. It seems as if almost every angle ofObamacare—positive or negative—has been covered several times over.And it's not likely to slow down, either.

But there is one group that has largely been ignored by the massmedia even though its members have been profoundly impacted by thelaw: the insurance commissioners who oversee state insuranceregulatory agencies. Some of them have seen significant impacts totheir daily job and the divisions or offices they oversee.

Some states opted to let consumers buy health insurance throughthe federal exchange or refused to take new Medicaid dollars, whichmeant insurance commissioners and divisions saw very little changedue to PPACA. While officials might have assembled some literatureor sent officials out to answer questions from consumers orbenefits agents, there weren't calls for more resources oremployees.

However, states that built health insurance exchanges andparticipated in PPACA saw additions to staff, larger budgetrequests and employees working overtime. Outreach efforts wereundertaken to educate various stakeholders in the new law,including town hall meetings, web seminars and new publications.Insurance divisions or offices also have had to forge closerworking relationships with other state agencies—as well as thefederal government—in order to meet the demands of PPACA.

“There were a few periods of craziness,” says Laura Cali,insurance commissioner for Oregon. “We would get down to the wirein terms of reviewing filings. We have our own deadlines andtargets for quickly turning things around; on top of that, therewere hard deadlines to get things to the exchange to make sure theyhad time to do their work. That pushed us to do whatever it took toget the work done.”

Overtime

The first issue to crop up for most insurance commissioners wasan increased workload—for themselves and their employees. Manyinsurance commissioners attributed the extra hours to PPACA'stiming. In many instances, plans had to be reviewed and exchangesbuilt in a short amount of time to meet the Jan. 1, 2014, deadline.And it didn't help that the law was delayed, either.

“We reviewed the bill and we started meeting immediately withour constituencies—the chamber of commerce, the medical community,the insurance companies—and soliciting their input. We used it tomake decisions and recommendations to the governor,” says SharonClark, insurance commissioner for Kentucky. “We were building theexchange, and we didn't know if it would be upheld by law. But wewent ahead with it. If not, we would not have met thedeadline.”

Some insurance commissioners added staff to help with PPACAdeadlines. Many of those staffers were funded through federalgrants and began work in the rate review and market analysis areas.There were even grants to hire people to help explain PPACA toconsumers.

“Our first grant from the federal government allowed us to train500 people,” says Jay Bradford, commissioner of insurance forArkansas. “It's synonymous with navigator. We’ve hired 500people—trained by community colleges like census workers—and theyconsulted with various groups. They go to churches or shoppingcenters and they tell people their options under PPACA.”

Insurance commissioners also saw that there needed to be morecollaboration within their divisions to keep up with PPACA's timecrunch. For some, that meant putting together a working groupwithin the division, but employees also were called upon to workwith other state agencies—especially those responsible forlaunching the state health insurance exchanges.

“Our roles and responsibilities expanded significantly, more interms of the health connector,” says Hawaii Commissioner ofInsurance Gordon Ito. “We created a task force to start thatprocess during the initial planning grant. We worked with thelegislature. We already had health-rate review in Hawaii, but withthe exchanges, we were really involved with the planmanagement.”

In Iowa, the implementation team met every week and featured“open hours” with health insurance industry representatives.

“I did put together an internal PPACA implementation team,” IowaInsurance Commissioner Nick Gerhart says. “I really pulled peoplein from different areas and put together a team that had peoplefrom the consumer side, communications, and all the different areasand put them together with a project manager. That really helpedstreamline the implementation.”

There also were relationships to be cultivated with the federalgovernment. Those interactions meant getting PPACA questionsanswered or the new law clarified by federal officials. And inArkansas, local politicians led by Gov. Don Beebe approached thefederal government about building a “private option” throughMedicaid.

Cost

For many insurance commissioners, the human factor was big. Butthere was a cost factor, too. The federal government providedfunding for many states to assist with parts of PPACAimplementation. Getting funding from state legislatures, however,was another matter. Many insurance commissioners didn't requestextra funding at all.

“When we have new responsibilities given to us, we try to workwith the resources we have,” Clark says. “We did receive somefunding through rate-review grants and consumer advocacy grants.And you have to realize that getting people on a state governmentjob—it was not something we could turn around on a dime.”

“We’ve held our own; we’ve survived the worst of it terms ofresources,” Gerhart says. “I didn't request any new staff in thenext two fiscal years.”

As PPACA moves forward, though, some commissioners have begunlooking to add these contract workers to the full-time payroll. Itosays federal grants funded nine positions in his office, but he'sasked his state legislature to fund six full-time positions afterthe grants run out. Ito says the positions will help handle extrawork created by the increased number of plan filings Hawaii sees asa result of PPACA.

“We had to add staff,” Ito says. “Initially, through the grants,we added investigators. On another grant we received for thehealth-rate review, we added more analysts as well as a healthactuary. Right now, they’re grant funded, but we have put in arequest to convert some of those positions to state funding.”

Outreach

Insurance commissioners also found themselves needing to explaina vast and complex law to many different constituent groups. Someof the first groups they approached were consumers—who wererequired by law to purchase health insurance. With all the newsflying around about PPACA, consumers had plenty of questionsregarding parts of the law, including the individual mandate andsubsidies. Others wanted to know how their existing plans weregoing to be affected.

“We got a lot of questions,” Clark says. “I think the maindifference is, before, with a lot of questions, they may have beena bit more sophisticated. Now, there's a new group of folks who’venever had health insurance before. We’ve had to go back and revampa lot of our consumer publications for people who are not familiarwith insurance terminology.”

Insurance commissioners say their divisions and offices expandedthe ways they communicated with consumers and other interestedparties, including town hall meetings, webinars, phone lines andpublications. Cali says the Oregon division tried to act as aninformation source for consumers.

“We tried to be as informational as possible,” Cali says. “Weweren't driving home the mandate as much, but we did let peopleknow when it would start and what the penalty would be. We advisedconsumers to talk to agents or to tax professionals. We also saidsome people might see rate increases, while some people might seethem decrease.”

Another way of getting the word out to consumers is throughbrokers and agents. Some insurance divisions immediately leveragedbrokers and agents to help consumers while others are justbeginning to rely on them to help educate the public.

“We put together materials for brokers and agents; we had acouple of webinars for agents and brokers,” Gerhart says. “We triedto include them. We did collaborative workshops, and we’ve beentrying to be very inclusive. In Iowa, we have 10–11 navigators, soagents and brokers are a critical part of success. Our message hasbeen that for this thing to be a success, we need local agents andbrokers.”

Oregon's Cali agrees.

“We need to work more closely with brokers and agents. They’reacross from a client explaining their options, so it's importantthat we get them accurate information,” she says. “We think that'sa critical area for us to continue to develop.”