IN EAST TEXAS: Surprise Ripples Through Health Care Community After Ruling
By COSHANDRA DILLARD
Medical and public health officials in Tyler said they are surprised the U.S. Supreme Court Thursday upheld all of the Affordable Care Act, the controversial health care law enacted by Congress in 2010.
Paying close attention to reports as news unfolded over the past few days, they believed that at least the individual mandate would be struck down.
"I actually thought that they would challenge some of the law," said George Roberts, chief executive officer at Northeast Texas Public Health District. "I did not think it would come through all the way."
Dr. Claire Tibiletti, president of the Smith County Medical Society and a pain management specialist at Azalea Orthopedics, was shocked by the outcome as well.
"I definitely thought the mandate would be (struck down)," she said. "I thought they'd tweak some of the smaller items, especially the one that affects Texas Spine and Joint Hospitals where it said no physician-owned hospitals are permitted to expand. That's an odd part of the law."
In the law, physician-owned hospitals such as Texas Spine and Joint, which Dr. Tibiletti is part owner of, cannot expand. Critics have alleged that physicians may have a conflict of interest if they refer patients to hospitals they have a financial interest in.
The key part of the legislation, the individual mandate, requires all citizens to purchase health insurance when that portion of the law is implemented in 2014.
The individual mandate was not upheld based on Congress's power to regulate commerce between states to require people to buy health insurance. However, in a 5-4 vote, the justices said that because individuals can refuse to buy insurance and face a penalty, it is a kind of tax Congress can impose using taxing power.
Another huge part of the law was the requirement to expand Medicaid eligibility. Effective April 2010, states receive federal matching funds to expand the program. In that law, it required states to comply with the new eligibility requirements or lose funding.
However, the government cannot threaten with loss of funding if they choose not to expand Medicaid, the court said.
The Texas Medical Society, a group representing nearly 46,000 doctors, in a statement Thursday said there needs to be a way of better caring for the uninsured population. The Smith County Medical Society, a chapter of TMA, aligns with the group's message.
They have contended since the debate about health care reform began that there were parts of the legislation they approved of, while others need to be fixed.
"We need a local/state/federal partnership to design a fair and sustainable system," the statement read. "Top-down mandates are not the answer."
The group recommends that Congress and the Texas Legislature fix the Medicare physician payment formula, allow Medicare patients to contract directly with their physicians for any covered service and lift restrictions on physician hospital ownership, among other things.
"I do think there are good things in the law," Dr. Tibeletti said. "I just think the way the whole law was presented and voted on in such as rushed manner didn't allow -- even the people voting on the law -- any of us to look at it and offer suggestions or improve it."
The health care law was spurred by a need to tackle health care spending, which reached $2.6 trillion in 2010, or 17 percent of the nation's gross domestic product, according to a 2012 report compiled by the Centers for Medicare and Medicaid Services' Office of the Actuary.
Texas leads the nation with uninsured citizens, according to 2010 U.S. Census data. Twenty-five percent of Texans are uninsured, which includes 17 percent of children and 33 percent of adults ages 19 to 64.
Roberts sees some benefits and disadvantages of the law. A lot of funding went to public health programs as part of the health care law's $15 billion Prevention and Public Health Fund. He said prevention programs are critical to driving down health costs.
"We are receiving the Community Transformation Grant, which is being funded through the Affordable Care Act," he said. "That funding will continue at this point. So we view that as a positive. If we're going to get a handle on health care costs, we've got to get healthier."
He added, "On one hand we're talking about insuring many, many more Americans. There's a lot of prevention types of things in the health care act that remain. The challenge is going to be -- it's a very expensive law -- how will we pay for it?"
Good news for access
to care advocates
Dr. Gary Gross, an oncologist at Blood and Cancer Center of East Texas and president-elect of the Smith County Medical Society, has been vocal about the need for more people to have access to health care.
Dr. Gross, too, was stunned but pleased that the Supreme Court upheld the controversial law.
"Our patients' lives have already been improved by it," he said.
Gross said he sees the problems firsthand with patients who are uninsured or who cannot afford the health insurance they already have.
"It makes it very hard as physicians to take care of everybody, particularly in oncology, where the cost of treatment is so extremely high," he said. "We're beholden to the drug companies to try to find ways to get these expensive treatments."
The cost of cancer treatment can run as high as $20,000 per treatment and the total cost could reach $100,000. At the least, patients may pay $3,000, Gross said.
Of those who have insurance, there still may be an issue with paying for their co-pays. Gross said it's "prohibitively expensive." He said expanding coverage to patients will decrease, not drive up costs.
"The patients who have no insurance are coming to our practice now and everybody else's practice," he said. "If you're a surgeon, you can tell someone, 'Don't show up unless you have $10,000 to pay for your surgery,' but if you're in primary care you can't turn people away at the door. We're seeing these patients anyway. It's an opportunity to have more of their care reimbursed, which allows, ultimately, less cost shifting."
Gross compared the individual mandate to the requirement to buy car insurance and said the government did a "miserable" job in communicating the benefits of the new health care law.
"The bill isn't that bad," he said. "The delivery of it has been awful, I think."
Doctors and other medical professionals can agree that the current health care system needed change, however, like other Americans, they are unsure how it should be changed and how to fund it.
"It's very clear-cut that we need change," Dr. Tibiletti said. "There is no question about that. Health care has become so terrible expensive that access to care is limited, and it shouldn't be that way."
She added, "The issue that is of great concern to me is funding. It's placing a huge burden on the states to increase the Medicaid access. We don't want to offer access to care and then greatly raise their taxes."
Dr. Tibeletti also is worried about the doctor-patient relationship, believing the patient will suffer as bureaucratic policies determine who can receive certain procedures.
"Every physician in practice takes the Hippocratic oath to do what's in the best interest of the patient," she said. "That's a fortunate thing because we'll continue to do that. The health care act is a very, very challenging change. I don't think any of us will know how dramatic it will be. It will not make it easier to care for patients."
Gross said the doctor-patient relationship is compromised more so by the health care system as a whole, rather than the new law.
"Commercial insurance payers are much more difficult to deal with than Medicare as far as getting things paid for," he said. "We're negotiating constantly. ... A lot of decisions are being made by clerks looking at computer screens about what's allowable and what's not. I understand the rationale for that. There's got to be some cost-cutting so our society survives or else health care costs are going to completely destroy any ability of our country to survive and thrive as a major world power."
During a news conference Thursday, Texas Attorney General Greg Abbott said he did not agree with the U.S. Supreme Court's ruling and that there "will be multiple uncertainties spawned by today's decisions."
"A new tax was imposed on Americans across the state and country today. ... I am against this tax," he said. "I will work with the state of Texas and members of Congress to repeal this unprecedented tax imposed on Texas."
In 2014, when the individual mandate will affect all citizens, states are supposed to have in place a competitive insurance marketplace for individuals and small businesses to purchase affordable plans.
Abbott said he was unsure when and how this will play out in Texas. He said the Medicaid expansion is a policy decision determined by the state.
The Medicaid payment rate to physicians is expected to increase to match those of Medicare reimbursement rates.
Gross said funding for the addition of more insured Americans comes from a larger pool, which is why he believes the individual mandate was enacted.
"I think expanding the coverage is going to, hopefully, allow us to treat more patients," he said. "The real reason that I think it's important that the mandate held is you cannot provide more services for more people without increasing the size of the financial (pool). The risk pool has to include healthy people. The insurance companies need to have money from healthy people to allow them to afford to pay for health care for unhealthy people ...
"The smaller that pool, the higher the premiums have to be for the people actually paying to cover the cost of delivering care to sick people."
Components of the health care law have been enacted since it was signed into law and key provisions will be added through 2015. The key features enacted since 2010 include: providing access to insurance for uninsured individuals with pre-existing conditions, extending coverage to young adults up to 26 on their parents' plans and allowing states to expand Medicaid eligibility.
"When you say, 'Oh I hate Obamacare,' the 'Obamacare' has only done two things: Everyone can get insured by their parents up to age 26 and we have a government-sponsored health insurance program where we're able to get insurance for our patients who have cancer already. Even in our relatively small practice, we've got almost 15 patients who simply could not have gotten treated."
Feedback about the health care law from patients is typically negative, Gross said, but he believes it's not from an understanding of the health care law, but rather, from the deep-rooted American ideal of being free from government intrusion.
"I never understood the people's resistance and resentment, other than the basic resistance to government telling me what to do," he said.