Robert M. Centor, MD; Joseph Li, MD; Désirée A. Lie, MD, MSEd; Robert W. Morrow, MD; Roy M. Poses, MD; Charles P. Vega, MD; Mark E. Williams, MD


July 09, 2012

Editor's Note:
On June 28, 2012, the Supreme Court ruled that 2 key and controversial provisions contained in the Affordable Care Act (ACA) were constitutional: the individual mandate and state expansion of Medicaid. The press has covered these issues extensively, focusing on the consequences for patients and the general public. We asked members from our internal medicine and family medicine advisory boards about their thoughts and how the Court's decision might affect primary care physicians.

The View From Family Physicians

Charles P. Vega, MD

Personally, I found myself far more emotionally invested in this decision than I thought I might be. I've been anxious and increasingly pessimistic about the decision over the past few months, and so it was an incredible relief to find out that the Supreme Court eventually did the right thing.

For the most part, I felt relief for the millions who will now join the healthcare system and not start in the negative when it comes to their well-being and ability to contribute to their families and society. It is a relief as well that equality will be greater in the way that healthcare is delivered, and preventive care will be emphasized as never before.

Finally, it's a relief to know that the most significant healthcare reform in decades lives least for now. If the ACA were to be struck down, it would be at least 5 years (and probably significantly longer) before any politician would have the courage to take on the issue of reform again in any meaningful way. In the meantime, many would suffer and die unnecessarily.

The ACA is a compromise that clearly pushes the limits of our collective political will as a nation. It does some things well (primarily opening up means to obtain health coverage for the uninsured) and some things poorly, like control costs. The Supreme Court decision breathes life into the healthcare reform movement at a critical time, and we need to take advantage of this fortune, not only to implement the most important parts of ACA but also to start building toward the next logical steps in healthcare reform, beginning with an efficient public option that emphasizes smart, quality care.

Robert W. Morrow, MD

It is hard not to throw up my hands and shout "Goaallllll!!!" but that's childish. No, it's appropriate. Our real goal now is equality through a single payer, or at the least a public option. All pharma prices should be negotiated as a matter of national security, as with the VA and Medicaid. Immunizations should be nationalized. And no training funds for subspecialties without a public payback! OK, primary care should have a public payback too. But for just this moment, what a good thing it is that the needs of the uninsured are being addressed, if not solved.

Is the following a unique thought? Well, indeed, someone discussed it with me, so it is neither a unique thought nor my own; so few thoughts in my head are either unique or my own. Happily, owning thoughts as property never appealed to me.

Let me recommend A Planet of Viruses by Carl Zimmer, which will reshape your thoughts about life here on Earth. It is a science book, not a motivational or opinion piece. Here's the virus that I caught: Our ability to negotiate as physicians has been held in check by the Sherman Anti-Trust Act, which has been -- ahem -- twisted to consider health plan monopolies as "purchasers," and docs as "sellers," and it ignores the mentioned monopoly power of health plans to dictate prices, the shape of the market, and the fundamental allocation of resources that determine each state's health of its public.

Bear with me on this.

The ACA switches the locus of control and regulation to the federal government and ultimately away from the states. Now an overwhelming piece of the healthcare pie is in federal hands. Does this change our relation to the Sherman Act?

Do we now have a regulator which needs to hold hearings and muster votes before establishing prices? Would the US government feel comfortable discussing these conditions of work in order to improve the health of the population, like Canada?

Think primarily of the support of primary care through agreed mechanisms in order to decrease the infant mortality rate, the stroke rate, the hypertension rate. We know that appropriate supply of primary care to the nation is fundamental to the welfare of the people. Think of disparities.

Are we now in a regulatory space where the health of the public could take precedence over the profits of the commercial health plans? Why not?

Let's bargain!

Desiree A Lie, MD, MSEd

The passing of the ACA by the judiciary branch does not assure its success. There are lots of obstacles still ahead, among which are (1) the tax penalty is insufficient ($680 maximum) to deter citizens from not having health insurance; and (2) not enough attention was paid to reimbursement for primary care; much of the cost burden will fall there.

Chief Justice Roberts will leave a legacy of minimalism (noninterference with the legislative branch) by his vote and the unique stance he took to pass the ACA.


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