As President Barack Obama signed the historic health care bill today, questions remain about how it will change health care at the local level.

As President Barack Obama signed the historic health care bill today, questions remain about how it will change health care at the local level.

The House voted late Sunday to approve the bill, however, the Senate has not yet approved the final revisions to the bill. It is expected to extend coverage to 32 million uninsured Americans and contains insurance reform policies, which go into effect this year.  

Gary Duncan, president and chief executive officer for Freeman Health System, said changes that will affect local health care providers are still a bit fuzzy.

“I think that in another month or so there will be lots and lots of information on it,” Duncan said. “It’s just a little too early yet.”

The bill does expect contributions from hospitals across the country, with a $155 billion cut on Medicare.

“The whole theory behind this bill is that the hospitals put that money in and in return two things happen,” Duncan said. “You have the uninsured who now, ultimately, have to have insurance one way or another – either on Medicaid or through purchasing insurance – the theory being that you make up the $155 billion in adding people to Medicaid rolls and then the uninsured purchase insurance through exchanges or whatever.

“The positive side of this is we’re going to see people before they’re really, really sick,” Duncan said.

Gary Pulsiper, president and CEO of St. John’s Regional Medical Center, is optimistic that reforms will allow wider access to health care.

Health care for the uninsured can be a misnomer, he said, because they often end up in the emergency room where there is no follow up visit and no health history.

“What often happens with those folks that don’t have coverage is they wait until the last minute and they go to the emergency room,” Pulsiper said. “And although they provide great care in the ERs it’s episodic care, it’s not that good care that we get from family practice physicians, so from that perspective we’re hoping that it’s a positive thing.”

A pilot program in Springfield paired the Mercy system with Medicare.

“Medicare said, OK, you take this population of people that have these problems, see if you can treat them better and actually save us money,” Pulsiper said.

An on-call nurse and patient follow up showed results. He sees a great future in the concept of a medical home or advanced primary care where doctors and nurses watch out for patients and check on them, especially those with a chronic condition.

“That’s the kind of thing that I think really starts to change health care long term is we get more involved with people and help them manage their own diseases,” Pulsiper said. “Keep them out of hospitals, keep them happier and healthier.”

Insurance reforms, both said, should help.

The bill offers tax credits to small businesses to make insurance coverage more affordable, clips pre-existing coverage exclusions for children, requires insurance companies to keep adult children on the family policy until they turn 26 and adds an annual wellness visit for Medicare recipients. It cancels lifetime limits on coverage and regulates annual limits and is supposed to close the Medicare “doughnut hole.”

Republicans, none of whom voted for the bill in the House, counter that the bill will offer coverage to only 94 percent of individuals and expand Medicare, increasing the number of people in the program by 40 percent.

A $750 penalty for not carrying qualified health insurance will begin in 2014.

An estimate by the Congressional Budget Office put the bill’s cost at $848 billion from when the plan begins to phase in this year until end of fiscal year 2019.

The bill calls for increased funding to train doctors and nurses, something Duncan said he sees as the biggest challenge – finding doctors to provide the care.

The call for nurse practitioners, he anticipates, will go up and while the bill will help with scholarships and some loan forgiveness, Duncan would like to see more.

“If you’ve got 35 million people, plus or minus a few million, and all of the sudden they are empowered with health insurance, then the problem becomes where do they go to get the service,” Duncan said. “There are not enough primary care providers to have the access for 35 million people.”

Primary care physicians are some of the lowest paid doctors and students can rack up $150,000-$200,000 in loans before they graduate. In Massachusetts, where health care reform was passed in 2006, Duncan said patients flocked back to the emergency room because of a lack of doctors.

However, until the bill is finalized by the Senate and implementation rules start to trickle down, there is still a degree of uncertainty on how the sweeping reform will affect local providers.

“We’re going to wait until the final rules are written to see what really matters,” Pulsiper said.

Duncan said, overall, things should get better for patients as changes are implemented.

“I don’t think the patients are going to see any changes,” Duncan said. “They’re certainly not going to see any change in the way we approach patient care.