Paul Hensler is certainly not alone in saying public health officials are "living in a time of incredible uncertainty."

As the CEO of Kern Medical Center, a county hospital in Bakersfield, Calif., Hensler says his top concern is not having to meet the raft of funded and unfunded federal mandates, or figuring out how make his institution financially sustainable during recessionary times. Rather, it's not knowing what the future holds – particular with regard to a pair of imminent, intertwined decisions: the forthcoming Supreme Court ruling on the Patient Protection and Affordable Care Act, and the November elections.

Government Health IT spoke with Hensler about that uncertainty, the potential for public hospitals such as Kern to gear up for Medicaid expansion only to be de-funded while still having to to take on just as many new patients, and how health insurance exchanges could be the back door into a single-payer system.

Q: As a public health center, what are your chief concerns right now?
A: The major concern is, first, what will the Supreme Court decide on health reform, and then, a few months later, what happens in the November election? With all the possible permutations of what the Supreme Court decides combined with which way the House, Senate, and White House go, we’re living in a time of incredible uncertainty about what’s going to happen to the healthcare system six months from now. That’s probably foremost in our mind.

Q: What about the Supreme Court case and the upcoming elections concerns you most?
A: Primarily the uncertainty. We can pretty much adapt to just about anything that happens, but when you don’t know what is going to happen, that is a whole lot more difficult – and the changes could be profound. We’ve gone down the road of planning that most of our uninsured patients will become insured. We need to be more competitive and have better patient satisfaction. We’ve been working hard to increase first-available appointments in our clinics, to be more accessible. If it turns out that we don’t get universal coverage, then we’ve built a more expensive system to take care of patients that still aren’t insured.

Q: It sounds as if, should the Supreme Court strike down the individual mandate, the Medicaid expansion provision or the entire ACA, you would still have a very similar situation, only without federal funding?
A: It depends on the scenario, but several possible scenarios look like that. In our geographical area, we’re heavy agriculture, a lot of our patients are not documented. Of course they’re not included under health reform, so even if it goes through as planned, they’re taking away a lot of the funds we receive for disproportionate share hospitals, safety net care pool funds, and things like that, under the assumption that everyone will be insured so it’s not necessary anymore. But we could very well end up losing all the funds for the uninsured and at the same time have uninsured. 

[Podcast: The uncertain future of health insurance exchanges.]

Then off on the other extreme, one of my worries on the foreseeable horizon is personnel. The health care workers are aging and the population is aging so we’re going to end up with more patients for fewer healthcare workers. Then dumping a whole lot of previously uninsured people on the system who want to use their new insurance card, and even now there are fewer residency slots for graduating physicians than there are medical school graduates each year. So the whole health education and training is out of kilter with the demand.

Read the rest of our interview with Kern CEO Paul Hensler on the next page.