Throughout the implementation of the Patient Protection and Affordable Care Act, Americans have been treated to story after story detailing the landmark law’s effect on a variety of people.

There have been stories about cancer patients losing affordable plans and prescription coverage. There have been stories of brokers working with clients to select new plans or discuss government subsidies even though no commission is involved. There were stories about President Barack Obama symbolically signing up for health insurance according to the dictates of his signature domestic policy achievement. It seems as if almost every angle of PPACA — 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 mass media even though its members have been profoundly impacted by the law: the insurance commissioners who oversee state insurance regulatory agencies. Some of them have seen significant impacts to their daily job and the divisions or offices they oversee.

Some states opted to let consumers buy health insurance through the federal exchange or refused to take new Medicaid dollars, which meant insurance commissioners and divisions saw very little change due to PPACA. While officials might have assembled some literature or sent officials out to answer questions from consumers or benefits agents, there weren’t calls for more resources or employees.

However, states that built health insurance exchanges and participated in PPACA saw additions to staff, larger budget requests and employees working overtime. Outreach efforts were undertaken 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 closer working relationships with other state agencies — as well as the federal 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 wire in terms of reviewing filings. We have our own deadlines and targets for quickly turning things around; on top of that, there were hard deadlines to get things to the exchange to make sure they had time to do their work. That pushed us to do whatever it took to get the work done.”

Overtime

The first issue to crop up for most insurance commissioners was an increased workload — for themselves and their employees. Many insurance commissioners attributed the extra hours to PPACA’s timing. In many instances, plans had to be reviewed and exchanges built 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 with our constituencies—the chamber of commerce, the medical community, the insurance companies — and soliciting their input. We used it to make decisions and recommendations to the governor,” says Sharon Clark, insurance commissioner for Kentucky. “We were building the exchange, and we didn’t know if it would be upheld by law. But we went ahead with it. If not, we would not have met the deadline.”

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

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

Insurance commissioners also saw that there needed to be more collaboration within their divisions to keep up with PPACA’s time crunch. For some, that meant putting together a working group within the division, but employees also were called upon to work with other state agencies — especially those responsible for launching the state health insurance exchanges.

“Our roles and responsibilities expanded significantly, more in terms of the health connector,” says Hawaii Commissioner of Insurance Gordon Ito. “We created a task force to start that process during the initial planning grant. We worked with the legislature. We already had health-rate review in Hawaii, but with the exchanges, we were really involved with the plan management.”

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,” Iowa Insurance Commissioner Nick Gerhart says. “I really pulled people in from different areas and put together a team that had people from the consumer side, communications, and all the different areas and put them together with a project manager. That really helped streamline the implementation.”

There also were relationships to be cultivated with the federal government. Those interactions meant getting PPACA questions answered or the new law clarified by federal officials. And in Arkansas, local politicians led by Gov. Mike Beebe approached the federal government about building a “private option” through Medicaid.

Cost

For many insurance commissioners, the human factor was big. But there was a cost factor, too. The federal government provided funding for many states to assist with parts of PPACA implementation. Getting funding from state legislatures, however, was another matter. Many insurance commissioners didn’t request extra funding at all.

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

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

As PPACA moves forward, though, some commissioners have begun looking to add these contract workers to the full-time payroll. Ito says federal grants funded nine positions in his office, but he’s asked his state legislature to fund six full-time positions after the grants run out. Ito says the positions will help handle extra work created by the increased number of plan filings Hawaii sees as a result of PPACA.

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

Outreach

Insurance commissioners also found themselves needing to explain a vast and complex law to many different constituent groups. Some of the first groups they approached were consumers — who were required by law to purchase health insurance. With all the news flying around about PPACA, consumers had plenty of questions regarding parts of the law, including the individual mandate and subsidies. Others wanted to know how their existing plans were going to be affected.

“We got a lot of questions,” Clark says. “I think the main difference is, before, with a lot of questions, they may have been a bit more sophisticated. Now, there’s a new group of folks who’ve never had health insurance before. We’ve had to go back and revamp a lot of our consumer publications for people who are not familiar with insurance terminology.”

Insurance commissioners say their divisions and offices expanded the ways they communicated with consumers and other interested parties, including town hall meetings, webinars, phone lines and publications. Cali says the Oregon division tried to act as an information source for consumers.

“We tried to be as informational as possible,” Cali says. “We weren’t driving home the mandate as much, but we did let people know when it would start and what the penalty would be. We advised consumers to talk to agents or to tax professionals. We also said some people might see rate increases, while some people might see them decrease.”

Another way of getting the word out to consumers is through brokers and agents. Some insurance divisions immediately leveraged brokers and agents to help consumers while others are just beginning to rely on them to help educate the public.

See also: Study reveals hot spots for marketing PPACA

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

Oregon’s Cali agrees.

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