The Affordable Care Act and Landmark SCOTUS Decision Explained

What an exciting week with the SCOTUS decision regarding the personal mandate! To summarize for those not glued to the coverage of this event, the Supreme Court decided that the Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional.  The penalty that an individual who chooses to go uninsured must pay is considered to be a kind of tax that Congress can impose because of its taxing power.  Because the mandate survived, the Court did not need to decide what other parts of the statute were constitutional, except a provision that required states to comply with new eligibility requirements for Medicaid (covering everyone that is below 133% of the poverty level) or risk losing their funding.  On that question, the Court held that the provision was constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.


I personally believe that since all citizens will utilize healthcare at some point in their lives, all citizens should have to contribute to the healthcare spending pool.  It’s no wonder our system can’t pay for services when so many healthy people are choosing to not buy insurance out of the misguided hope that they will not need to utilize healthcare at some point.  The analogy I always make is how long would a home owner’s insurance company stay in business if only people planning on burning their homes down this year buy a policy?!? We need those NOT immediately cashing in on the system to be paying in so that there is money to pay for those who are using it.  When these same “investors” ultimately need healthcare, those who are healthy will in turn fund their care.  It is the ultimate “pay it forward” philosophy.


But obviously NOTHING is ever this simple.  In addition to providing access to care, we need to make sure we are training an adequate number of qualified physicians to meet this need.  We need to make sure these doctors are coming out trained to manage a complex healthcare delivery ecosystem where understanding the needs and expectations of the consumer (aka “patient”) is as important as knowing how to treat the disease process.  As Atul Gawande says, physicians can no longer operate as cowboys, they need to function in the health care arena as an efficeint pit crew, which requires understanding their roles and responsibilities as part of a team, not as a savior.  In the words of healthcare cousultant Paulo Machado (@pjmachado), doctors now need to function as health care sherpas – badass mountain climbers with backs like armadillos that can use their knowledge of the healthcare system to lug the patient and their family up the mountain towards maximal health and wellbeing.  Like the sherpas in Nepal, this is not a glamorous job.  Nepalese sherpas are rarely on the camera in National Geographic films and do not get to stay in comped hotel rooms like the researchers they are serving.  But lugging all that gear is one of the most critical jobs!


Physicians are used to the limelight.  Historically, we’ve made an excellent living and have enjoyed our position on the pedastal society has placed us on as the Kings and Queens of the healthcare world.  So it’s no wonder that the shift to a team based mentality could be hard for those with particualarly big egos to swallow.  It’s a paradigm shift to understand that we have to engage our patients to achieve the best outomes.  It is the sum of these individual outcomes that leads to overall improved population health.


Of course, in addition to an insured population and well trained physicians we also need tort reform, system delivery reform, and outcomes research to ensure that our limited health care dollars are spent most effectively.  Two weeks ago I was asked to summarize some of the problems the healthcare system is facing and how the ACA is starting to address these issues to a group at UIC.  Below I have provided the slides from my talk.  I hope this is helpful to those of you doing your best to understand the complicated health care landscape.  After reviewing the slides, please post any additional questions you have below, and I will do my best to answer.  My ultimate stance, which is also shared by the American College of Physicians, is that the ACA is NOT perfect and still needs to be improved, but repeal at this point would have devastating consequences that many citizens are not even aware of.  I do not agree with every philosophy the democratic party espouses, but when it comes to healthcare, they’re miles ahead of the republican party when it comes to addressing pressing healthcare issues.  If these important issues are not addressed, our country will surely go bankrupt as a result of runaway health care costs.  When it comes to the ACA, we cannot afford to throw the baby out with the bathwater. 

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About Kara Nance MD

Kara Nance, MD FACP currently works in private practice in Rolling Meadows, IL. Dr. Nance approaches the care of her patients with a very holistic attitude that targets the many factors that contribute to overall wellbeing. She is a mother of 4 young children, and often brings her personal life experiences into play when helping her patients solve problems relating to life balance. In addition to her clinical practice, Dr. Nance is passionate about electronic medical records and the establishment of electronic health exchanges. She consults with local physicians, hospitals, and medical groups about transitioning over to electronic medical records. Kara also participates in advocacy activities relating to primary care. As a Fellow in the American College of Physicians and a member of the ACP's Northern Illinois Council, Dr. Nance frequently travels to Washington to lobby for important issues in health care reform.
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11 Responses to The Affordable Care Act and Landmark SCOTUS Decision Explained

  1. Michele Hauser says:

    Wonderfully clear explanation of a complicated subject, made more confusing by the partisan simplifications out there intended to sway the public rather than educate it. Your blog is great in that it clarifies healthcare issues. Thank you. Would that ALL physicians were so knowledgeable and willing to help their patients understand. Keep it coming!

  2. Alex Pociask says:

    "GREAT" explanation of why we CANNOT continue with the current USA Healthcare "status quo"!! As a Republican who supports "Obamacare", I have personnally experienced the current "screwed-up" USA Healthcare System and fully support any improvements that can be produced!! I hope others can put aside their current political affiliations to rationally examine the alternatives?? Stay tuned……….

  3. Christie Blodgett says:

    Great presentation! I will link it to the Thomson Memory facebook feed.

  4. How To Be Healthy Kara Nance MD says:

    Thank you for your kind words! So honored to be highlighted by The Thomson Memory Center, Dr. Blodgett! http://thomsonmemory.com/

  5. Simon says:

    Dr Nance,You could not be more rightBeing an Alien in the USA I alwys wondered why nobody sees this compared to any civilized country that does not accept that more then 20% of their population is un-insured

  6. Joannie says:

    Great presentation! I will follow. (Dr. Blodgett’s sister nurse=cousin!)

  7. K. McQuade, M.D. says:

    Hi Kara,Well, at the end of your blog you did ask me to post a response….As you might suspect, I have a different view of the SCOTUS decision last week.As a physician, like you, I agree with you that everyone should have access to quality health care and that our current system is broken. I just disagree as to how President Obama has decided to fix this. During the 2008 presidential campaign, Senator Obama promised, over and over again, that, as President, he would not raise taxes on households earning less than $250,000 per year. Then, in 2009, while his healthcare proposals were being debated in Congress, President Obama repeated, over and over again, that his healthcare plan would not require tax increases. He said his plan would utilize the existing private health insurance system, and promised that everyone would be allowed to keep his or her own health insurance plan if they wished. When then-House Speaker Nancy Pelosi was questioned about the provisions of the 2,000(?) plus page Obamacare bill, that she was ram-rodding through the House of Representatives, she was unable to answer. She honestly didn’t know what was contained in the bill. But, that didn’t bother her in the least. She simply explained that the Obamacare bill had to be enacted into law before anybody could possibly understand what the hell it was.That must be her idea of sound legislative practice. That’s my idea of legislative malpractice. Through a contorted and controversial process, that bill became law, and the American public is slowing learning some of its provisions. Last week, the United States Supreme Court agreed with President Obama’s own lawyers that Obamacare is first and foremost a complex and massive tax scheme (one that’s obviously aimed at households earning less than $250,000 per year). That’s why the act authorizes the hiring of so many more IRS agents. They, and their fellow federal bureaucrats, not medical professionals, will be the health sherpas under Obamacare. Independent payment advisory panels and task forces will distort the physician-patient relationship that has,up to now, been so important in the practice of medicine. The public is also learning that President’s "affordable" healthcare plan is anything but affordable. Health insurance premiums continue to increase at a rate many times greater that the overall rate of inflation. Employers, faced with these additional costs, in a miserable economy no less, are being coerced by Obamacare into dropping their employee health plans. Obmacare actually gives an incentive to employers to do this. The penalty for dropping their insurance plans is significantly less that the newly inflated premiums generated by Obamacare. It’s obvious that Obamacare is intended to eliminate the private health insurance industry entirely, in favor of a government run, single payer plan. One can but only imagine how bumbling and inefficient the federal government will be in running hospitals, nursing homes and medical practices.In addition, there has been no mention of the sustainable growth rate fix nor meaningful malpractice reform. I believe that there will be a significant increase on the demand side of medicine with a significant decline in the supply side. As you know, there are ever increasing numbers of physicians who no longer will accept new Medicare patients and many who are closing their practices entirely to Medicare patients. It does no good to give everyone a Medicaid card if there are no physicians who will accept the card. In addition, I find it insulting that the Government will try to incentivize physicians by paying them a bonus if they meet certain criteria. I,like you, will do the best for our patients regardless of any financial benefit.I think that the law should have addressed giving tax credits to individuals to purchase their own insurance and should have allowed individuals to have the ability to purchase insurance across state lines in order to foster competition between insurance companies.Up to now,no one has been able to adequately tell us how we will be able to afford this plan. Perhaps, I shouldn’t despair. As currently written, Obamacare vests a phenomenal, almost dictatorial amount of discretion in the hands of the Secretary of Health and Social Services. In many respects, Obamacare will be whatever any Secretary of Health and Social Services says it will be. So, with a change of administration, the law will change too. Of course, that’s a fairly disruptive way to administer one sixth of our national economy.

  8. Simon says:

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  9. Ann Anaya says:

    Dr. Nance – Thank you for posting your message. You are awesome! This is one of the reasons you are my Healthcare provider. This and the fact you are a wonderful, caring doctor. And, by the way, a woman who faces challenge like no one else I have ever met. You definitely do not stand in the way of progression. You embrace it and do what you can to increase the likelihood that we all benefit.Thank you!!!Ann

  10. Ann Anaya says:

    Dr. McQuade – You say in 2009, Obama promised not to raise taxes for HealthCare … well he kept his promise. The AHA will penalize only the individuals who can afford health care but choose not to participate. You will not be taxed for this. There will be no income tax increase for this. The individuals who do not have health care and can afford to purchase health care are the ones who contribute to health insurance companies increasing the rates from year to year. In essence, all insured pay for these individuals. Unfortunately, President Obama is only able to begin a system that has been long needed in this country. Reform is a good thing – no matter how many people resent it – it’s progression. This country needs to progress for the good of all the people. I will attach a link that my nephew who is running for State Senate in the State of Minnesota posted on his FB page. For those of you who do not know who would be required to pay a penalty if they are not insured, please read this. http://healthreform.kff.org/the-basics/Requirement-to-buy-coverage-flowchart.aspx

  11. K. McQuade, M.D. says:

    <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> <HTML><HEAD> <META content="text/html; charset=US-ASCII" http-equiv=Content-Type> <META name=GENERATOR content="MSHTML 8.00.6001.19258"></HEAD> <BODY style="FONT-FAMILY: Arial; COLOR: #000000; FONT-SIZE: 10pt" id=role_body bottomMargin=7 leftMargin=7 rightMargin=7 topMargin=7><FONT id=role_document color=#000000 size=2 face=Arial><FONT id=role_document color=#000000 size=2 face=Arial> <DIV> <DIV>Ann Anaya,</DIV> <DIV>&nbsp;</DIV> <DIV>First of all, let me preface all of this by saying I don’t twitter, I don’t tweet and I don’t twext. I’m not linked in , I’m not facebooked&nbsp;,myspace and I don’t blog.&nbsp;&nbsp;I don’t skype and&nbsp;I don’t facetime.&nbsp; </DIV> <DIV>As you may have surmised, I am more conservative than most. I don’t really consider myself a Republican but I am definitely not a Democrat.</DIV> <DIV>It’s just that I prefer less Government intrusion into my life. It seems&nbsp;that Obama’s plan for America is one where the Government&nbsp;rather than the individual&nbsp;controls more and more aspects of your life. </DIV> <DIV>Obama campaigned that his Administration was going to be "the most transparent administration that we had ever seen"! Clearly this was not the case. From it’s inception,&nbsp;Obamacare was pushed through as a&nbsp;&nbsp;"pass it now and read it later" bill. </DIV> <DIV>I think most of us realized that this entitlement program was really just going to be a massive tax bill, but that if our President at that time had told the American public that this&nbsp;was going&nbsp;be another tax,&nbsp; it never would have gotten off the ground. First it wasn’t a tax but now it is a tax. It sure does sound a&nbsp;lot like the old classic "bait and switch"! <DIV><SPAN style="FONT-FAMILY: null" mce_style="FONT-FAMILY: null">Beginning January 1, 2013, ObamaCare imposes a 3.8% Medicare tax on unearned income of "high-income" taxpayers which could apply to proceeds from the sale of single family homes, townhouses, co-ops, condominiums, and even rental income, depending on your individual circumstances and any capital gains tax exclusions. Importantly, the "high income" thresholds are not indexed for inflation so will reach increasing numbers of middle-class taxpayers over time.</SPAN></DIV> <DIV><SPAN style="FONT-FAMILY: null" mce_style="FONT-FAMILY: null">In February 2010, 5.02 million homes were sold, according to the National Association of Realtors (NAR). On any given day, the sale of a house, town-home, condominium, co-op, or other income from a rental property could slam middle-income families with a new tax they just can’t afford.</SPAN></DIV> <DIV><SPAN style="FONT-FAMILY: null" mce_style="FONT-FAMILY: null">This new ObamaCare tax is the first time the government will apply a 3.8 percent tax on unearned income. This new tax on home sales and unearned income and other Medicare taxes raise taxes more than $210 billion to pay for ObamaCare. The National Association of Realtors called this new Medicare tax on unearned income "destructive" and "ill-advised" and warned it would hurt job creation.&nbsp; In reality, the tax impact of Obamacare will reach to all except those deemed "poverty level" as savings accounts, money market earnings,</SPAN></DIV> <DIV><SPAN style="FONT-FAMILY: null" mce_style="FONT-FAMILY: null">401(k) earnings once utilized, investments of any sort (which the majority of Americans have in one form or another) will be now subject to these taxes.&nbsp; Your entire review regarding the tax effects are significantly wrong.&nbsp; My wife, who by the way read the bill, made a presentation to her Board of Directors (she is a Corp. VPHR) almost 2 years ago when this monstrosity was passed on its content – as she called it then, a bill loaded with taxes, regulations and little that benefits the people since access to medical care is not the main issue but who pays for it is. Just reference any Emergency room in the country.&nbsp; "Reform" does not equal positive change.&nbsp; This bill certainly reforms but way beyond the benefit of the few positives in it.&nbsp; "Change" is simply not always a good thing.&nbsp; </SPAN></DIV> <DIV><SPAN style="FONT-FAMILY: null" mce_style="FONT-FAMILY: null"></SPAN>&nbsp;</DIV></DIV> <DIV>To be fair, I don’t think Republicans have done much better in finding a health care solution. </DIV> <DIV>I do not believe that those who are happy with their current plans will be able to keep or afford them under Obamacare.&nbsp;Likewise, I don’t&nbsp;believe that this will save as much as predicted from the CBO. As I said previously, this plan has done nothing to address the SGR fix and these numbers alone&nbsp;can be&nbsp;staggering&nbsp;but seem to get left out of the mix. I find the incentive to pay physicians a bonus if we meet certain criteria by reporting to the PQRS to be ridiculous as it therefore implies that they will impose a penalty on those who fail to report such measures. I’m sick and tired of spending endless hours filling out paperwork knowing that this will only exponentially increase with more government intervention in healthcare.</DIV> <DIV>&nbsp;</DIV> <DIV>Likewise , by paying us a bonus to "hit" these data points, it&nbsp; implies that without&nbsp;the bonus , we would be less likely to do what is in the best interest of&nbsp;our patients.This is really a insult to all physicians.</DIV> <DIV>&nbsp;</DIV> <DIV>Finally,&nbsp;I know of no other country that is juggling as many entitlement programs as the U.S. is without suffering dire financial consequences as is evidenced currently&nbsp;throughout Europe.</DIV> <DIV>&nbsp;</DIV> <DIV>In addition, I know you are aware of the numerous cases of Medicare and Medicaid fraud that heave occurred under all&nbsp;recent administrations. I just don’t see how any sane person can believe that any federal agency could be able to efficiently and honestly administer heathcare based on the goverment’s&nbsp;previous record with any and all administrative services.</DIV> <DIV>&nbsp;</DIV> <DIV>Furthermore, in my mind, with our declining economy, rising debts&nbsp;and unemployment, I don’t see how we will ever be able to pay for this.&nbsp; The timing on yet another big government entitlement is irresponsible at best and fiscal suicide at worst.&nbsp; </DIV> <DIV>&nbsp;</DIV> <DIV>I am signing off and this will be my last response.</DIV></DIV> <DIV>&nbsp;</DIV> <DIV> <DIV>In a message dated 7/18/2012 11:35:48 A.M. Central Daylight Time,</DIV></DIV></BODY></HTML>

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