The SCOTUS ruling from one doctor’s perspetive

Today’s SCOTUS ruling really belongs to the lawyers, legal analysts and healthcare economists to discuss.  That’s certainly what I’ve been spending my time reading.  But since it pertains to healthcare, it seems like I should say something about the ruling.  Something about how I think it’s going to affect my practice?  What its impact on our patients will be?

Want to know the honest gospel truth?  I have no fishin’ clue.  None.

Actually, that’s not entirely true.  Since I practice in a state that already has mandatory health insurance thanks to a Republican former governor whose policies were suspiciously similar to the ACA (confidential to MR: your secret is safe with me), most of my patients are insured.  However, my office is close to the border of another state without a universal coverage law, and we have a lot of patients who cross the border for care.  What number of uninsured patients we have come from there.  Insofar as our practice has to write off costs because our self-pay patients just can’t pay them (which is not a huge amount), at least in the short term our bottom line might be helped a bit.

But in the long term?  I don’t know.  I have no idea what impact this law will have on reimbursement rates.  As a part owner of the practice, I have no idea what impact this law will have on the premiums we will have to pay for our employees.  Perhaps there’s an easy way to figure these answers out, but if there is I haven’t found it.  (Feel free to suggest resources in the comments.)

So there you have it.  Since there’s nothing in the law about what services will and won’t be paid for, the impact on the kind of medicine I practice seems pretty minimal.  But beyond that, I don’t know what this really means.  I do, however, promise to keep you posted.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Most of the parts that affect primary care, and thus my wife, weren’t really under review. The part that was involves Medicaid, which has been getting a lot of attention in the local medical community, but only because they were about to slash rates down to the point that hospitals would have to seriously reconsider taking on those patients (which, with hospitals as far apart as they are out here, is a pretty big deal). Since the ruling is more-or-less status quo, it *might* be helpful insofar as expanding coverage might have resulted in lower fees and the same problems faced last summer. Or it might have been helpful to have more people insured. I’m really not sure.

    • Yes, I am getting pretty dang sick of Medicaid cutting funding so much that all the halfway decent doctors won’t see the people I serve any more. If I have to deal with one more terribly insensative physician I’m going to lose it.

  2. I was umm… intrigued?… to see an email from my health care provider notifying me of how the ruling would impact the service I am receiving.

      • “… you need not be concerned about any disruption to your coverage and care resulting from the court’s decision…While political uncertainty still remains, we’ll continue to be guided by our goals of providing high-quality care, great service, and affordability to our members and the communities we serve. ” Blah, blah, blah.

        • I don’t know why, but I find the fact that somebody was paid to write that kind of amusing and inspiring. I wouldn’t mind pablum-for-dollars. 🙂

          • Oh no, Will. Don’t cross over to the dark side, please.

          • Hate to burst your bubble, Will, but it looks computer-generated to me. 🙂

  3. And yet many of my classmates spent yesterday screaming about quitting school, or (seriously) practicing in Canada.

    Out of the mouths of babes……

    • Did this strike you as mere bluster? Did it strike you as indicative of serious intention?

      I mean, *MY* take on the PPACA is that it did a lot to promise stuff to everybody without doing a whole lot to improve the lot of the people who actually have to provide it to people… so, at best, it struck me as not helpful and, at worst, as something that would create friction (or more friction) where there wasn’t friction (or at least as much friction) before… and, as such, would result in making things worse. (Now, I didn’t know if this merely meant longer queues or the establishment of a black market… but I figured it’d mean *SOMETHING*.)

      What did your classmates think would happen to them because of this law?

      • I said all kinds of stupid things when I was in medical school, too. (No offense, Ken.) It’s amusing that Canada is everyone’s default option, whether the odious trigger be the re-election of George W. Bush or the SCOTUS ruling upholding ObamaCare. Apparently, Canada waits with open arms for all American discontents, equally palatable to all.

        • They speak the language and if you’re willing to move to Alberta, everybody’s an ex-pat American anyway. It’s like living in a blue state surrounded by Texans.

        • But here’s the one reason I’ll respect Med Students talking about moving to Canada (or anyone who’s gotten informed about the choice):

          The PPACA is not universal health care. It’s a mandated open marked ~For Profit~ solution that “Sort of” moves us in the direction universal coverage and maybe, eventually, affordability. Canada (and the European model) are all single payer plans with the ability to upgrade if you wish to have more perks attached then the core program.

          There is still a fundamental difference between the two and an exodus makes sense if it’s by the people who ~want~ a true as close as you can get egalitarian system.

          Of course most of the nutjobs on Twitter are not so informed…..

          • I’d take the Canadian system. So would, I imagine, 95% of Americans if they didn’t keep hearing the screams of “Socialism!” and “Death panels!”.

            Strangely — or perhaps not — the people screaming the most about the ACA are people who don’t have employer insurance.

            I can’t get worked up about faceless government bureacrats when I’ve spent the last two decades dealing with faceless free market bureacrats.

            I’m afraid that some government functionary denying my care is unlikely to be doing so to add an extra digit to his CEO’s quarterly bonus. I might not LIKE the reason, but I’m hard pressed to find reasons more upsetting than “Because we want to pay our boss even more.” when it comes to telling me I can’t have the MRI my doctor recommended. And I can at least scream at my Congressman. The head of Cigna doesn’t really give two craps what I think, but my local House rep will occasionally pretend.

            Personally? I suspect we’ll end up with a minimum-level socialized system, with private ‘extras’ on top. Taxes pay for a minimum level of care and service and people pay to cover extra things (from private rooms to lower copays, whatever).

          • My worry about single-payer is more along the lines of the usual busybodies here using it as pretext for further intervention in our lives on fiscal (“your habits cost too much, citizen”) grounds.

      • They thought that it would fix healthcare! The same way that the CPSIA fixed the problem of children being exposed to lead!

  4. I was really hoping that the PPACA would be struck down. It seems to me to be another worthy cause betrayed by the passions of the moment. I see a lot more wrong about it than anything right about it, and it’s unlikely that there will be efforts to correct those deficiencies later.
    IMHO, the worst of the lot are:
    1) There will still be people without a basic level of coverage. We can argue over the finer points of what “basic” means, but in the meantime people will still suffer injuries and treatable conditions will linger and worsen into major illnesses. And that’s without considering the cost of having a baby.
    2) Our health insurance is tied even tighter to our employment. The official union line is that this evens the playing field between the union contractors and the non-union contractors, because the non-union contractors will be required to provide a benefits package for their employees. What I see is that I pay over $20k/yr for health insurance and still suffer lapses; and now I’m going to be taxed on the exorbitant premiums whether or not I get to enjoy them.
    3) I don’t see it doing anything for costs, which is one of the biggest problems here. And a lot of that goes back to figuring out what “basic” is (consider what having a supplemental policy for end of life care might do). Akin to #2 above, I see more of the wage increases going to the benefits package– this time of private employers.
    4) It still doesn’t make sense to me. It matters more whether I’m injured on the job or in a car wreck as to what I might be entitled to; and that makes no sense to me.

    What I see as the main effect is continued senselessness and impassioned outcries coupled with lack of foresight– same as before.
    I sincerely hope that you might later prove me wrong on that.
    I would be quite happy to be mistaken in this case.

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