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Tom Tape, M.D.

University of Nebraska Medical Center professor of internal medicine, and chair of the board of governors of the American College of Physicians, the nation’s largest medical specialty organization. 

What are the key points of the Patient Protection and Affordable Care Act that the Supreme Court ruled on today?
So the Affordable Care Act is a pretty complicated bill that has many, many provisions but they can be but they can be divided into sort of four particular areas. One area is to improve the access to health care insurance. Another area is to try to improve the quality of care provided by the Medicare system. A third area is to make improvements to the workforce so that we have enough health care providers to meet the demands of the newly insured patients. And finally, many provisions to try to make the system deliver better value. To try to do what’s called bend the cost curve. 

What did the judges rule and what was the sticking point?
So the Supreme Court ruling is that the court ruled on two provisions on the Affordable Care Act law that were being contested. The first was that whether an individual mandate was permissible. What the majority of the court ruled was that those who choose not to have insurance will be assessed a tax in lieu of having insurance and so in that way of looking at the mandate, not as a mandate but as a tax for not having insurance, the court ruled that that was permissible. The second issue the court considered was whether the provisions to expand Medicaid coverage above and beyond the current level of the Medicaid program amongst the various states. And what they ruled was, as long as there’s a narrow interpretation of the consequences to the states for non-participation, that it was in fact, constitutional. And the narrow interpretation is if the states don’t participate in the expansion of Medicaid, they will not get any additional funding from the federal government to support the Medicaid expansion, but they will not lose any money from their already existing Medicaid programs. To the layperson it means that in states which choose to accept the new federal money, and put in some of their own state funds, that the ability to qualify for Medicaid will be at a higher level of income than it is today. In many states if a person does not have dependent children, they won’t quality for Medicaid at all. And the new program provides Medicaid coverage for anybody up to 133 percent of the federal poverty level. So what this part of the law will allow is an expansion of that Medicaid system and it’s estimated that if every state were to participate, about 16 million Americans would qualify that don’t qualify today. 

Who is this ruling good for?
“I think on balance, I think the ruling is good for the entire health care system because it provides a path forward. Had we not been able to go forward with implementing this law, we would have really gone back to square one to deal with the challenging problems facing our health care system. And my fear was that given the amount of controversy that this law produced, and given the polarization of politics in this country, is that we wouldn’t get any meaningful health care reform legislation through in the foreseeable future. So I think it provides us a way forward even though it’s a rocky way forward.” 

How will the ruling benefit people?
“Well, there’s a whole number of parts of the law that have already been implemented that people have been pleased with. For example, the ability to have children up to the age of 26 covered under their parent’s policies. The provision that requires preventive care services to be covered without any co-pays on the part of the patient -- very popular provisions -- insurance companies have to spend a certain percentage of their income on the actual health care of the beneficiaries and just recently quite a few payments were made in the way of refunds from companies that didn’t meet that threshold, have been paid out. The very unpopular Medicare donut hole that faces senior citizens purchasing their medications is being phased out as part of the new law. There are a whole number of pilot programs trying to provide better ways of providing health care that are currently being tested and implemented. So it covers a broad spectrum.” 

Does anyone lose out in the ruling?
“The question of who might lose from the ruling is that it may pose a burden to certain employers that may feel that they are being coerced into providing insurance for their employees. There are certainly some incentives in the law to help small businesses in this regard. But I can’t say that nobody will be negatively impacted. We have a challenge to try to provide a better health care system that’s going to cost money as a whole. But I think it’s important to point out that our current health care system has a safety net in that anybody who is sick enough to need to go to an emergency room has to get their health care provided whether or not they can pay for it and those who can’t the rest of society ends up picking up the bills. The money is cost shifted from those who can’t afford it to those who have some way of paying for it. So, I’m a firm believer, as a primary care doctor, that we’d be better paying for health care up front in doctor’s offices and emphasizing prevention than we would waiting until patients are so sick they have to come into the emergency room, have emergency surgery, have hospitalizations which are extremely costly to the system. So, even though there may be individual areas where costs are shifted around a bit, I think for the society as a whole we’ll be better off with the new law in place.” 

How will the ruling impact costs in the long run?
“I don’t see that the total cost of health care, if we include the cost of providing the current emergency care for the uninsured…. If all that is taken into account, I don’t see that the overall cost is going to increase appreciably. In fact, if the cost saving measures of the Affordable Care Act begin to work in the long haul, I can see the cost of care actually coming under control.” 

Why is Medicaid expansion necessary?
“The reason for the Medicaid expansion is the concern that if a person is below this level of income, that they will not have the resources to afford to purchase health care insurance. There are in fact, subsidies available to people who are above the Medicaid threshold but still couldn’t afford the full costs to help them obtain insurance coverage.” 

How important is this day in health care?
“This really is a defining moment in deciding a way forward for the health care system in this country. And whether they declared the law unconstitutional or upheld the law as they did is going to have tremendous import for the future. I’m encouraged that I think we’re still on a path forward, we’ve got a lot of work to do, there’s still parts of the law that I think could be improved upon, there’s additional items we need to work on to try to improve the value of health care delivery in this country and try to get the costs down. And so I’m hoping we can get beyond the current controversy and start working on the important problems.” 

How does this affect the uninsured—those with pre-existing conditions?
“So the important part of the law for uninsured with preexisting conditions is that insurance companies can no longer decline to offer them affordable insurance because of their preexisting condition and that goes into effect in 2014.” 

What’s the next step?
Well, as far as I can see, the next step is the law will continue its phased implementation. The law was passed in 2010 and the law provided for a gradual implementation of its various provisions that extend for about 10 years. So the biggest step will be in 2014 when the actual insurance exchanges come into play and the individual mandate goes into effect.” 

What is the human cost of no health insurance?
“I have a tremendous amount of patients who do not have health insurance either because they’re self-employed or they work for an employer that does not offer health care insurance as part of their health care package and it’s a tremendous challenge to help these patients get good quality healthcare because they don’t have the ability to afford the types of treatments that they need. And I just saw a patient yesterday that declined to get a very necessary diagnostic test because he said he couldn’t afford to pay the cost of the test. And so finding a way for patients like that to obtain affordable health care insurance will make a tremendous difference. There’s data from the Institute of Medicine showing that people without insurance have higher mortality. So lack of health insurance is actually a risk factor for death in this country.” 

Juliann Sebastian, Ph.D.

Dean of the University of Nebraska Medical Center College of Nursing 

In 2014, there’s forecasted to be many more people seeking access to health care. How will the system meet those needs?
“I really do think that increasing access to health care is so important but we know that it will increase demand for health services and so those of us who are in higher education, educating future health professionals have to plan ahead for that. And the need for all of us to address workforce shortages in our state, here in Nebraska, as well as around the country, is just more pressing now than ever. In nursing as an example, some of the data around the United States, these are not Nebraska data, but around the U.S., show that the total number of job openings for nurses in the United States is projected to be 1.2 million by the year 2020. And this is for openings. So we are all working toward expanding our programs, we know that has been important for some time now -- that good work has been under way for a number of years, but we’ll need to think about the projected gap between now and 2020 and beyond so we can be sure that the work that we’re doing with expansion will really meet those needs.” 

How will research play a role in reducing health care costs?
“Well, one of the things I’m very excited about in the Affordable Care Act is the focus on innovative care delivery models. And I’m excited about it in part because here at the University of Nebraska Medical Center one of the things we do is research around best care -- what would be the most innovative cutting-edge care for people. As a nurse, I and my colleagues have long been concerned about coordination of care across settings and over time for people. We know that fragmented care is confusing, it can result in poor quality health outcomes, poor quality decision making when people don’t know what to do and so the focus on increasing coordination of care through new care delivery models I think is very, very exciting and this piece of legislation will foster more research, and more education and more practice around the matter of new and innovative care delivery models.” 

How will the health care system meet an increased demand for health care?
“One of the issues that’s very important is as people gain access to care, we hope they’ll seek care in primary care settings -- health care homes, medical homes. If they seek care first in a primary care setting focus on prevention, health promotion, wellness, those kinds of services, then the need for a more costly, more invasive and more serious care down the line will be reduced. But in order to seek care in primary care settings, we have to have enough clinicians educated to provide primary care. So that includes not only primary care physicians but also nurse practitioners and physician assistants who play a very important role in the full spectrum of primary care. So, one of the things that we’re concerned about in the College of Nursing is being able to educate the nurse practitioners who will be needed to work in team settings as part of teams to provide vital primary care services for the future. We know that nurse practitioners currently do work very effectively with patients and families and with physician colleagues, physician assistant colleagues and with other health professionals so the care that is provided is the very best possible, most comprehensive care.”