After SCOTUS Healthcare Ruling, No Middle Ground Will Remain

When the Supreme Court hands down its decision on whether or not the Patient Protection and Affordable Care Act is constitutional, Glen Stream, MD, FAAFP, MBI, president of the American Academy of Family Physicians (AAFP),  hopes he'll be in meetings and not making rounds in his clinic in Spokane, Wash.

That's because he wants to be available to respond to the flood of calls anticipated from the media—and even his fellow physicians. The high court is expected to decide this month whether the healthcare reform law should be overturned in full or in part, or remain intact. Stream, for one, is ready to give his opinion.

And that's in the middle of the road.

Stream is unlike a lot of his physician colleagues who detest the law and would love nothing better than to see it completely trashed by the Supreme Court.

Stream's AAFP, which represents 105,000 doctors, has supported the health care law. His association certainly isn't a cheerleader for it, though. The executive board supported the act, passed two years ago, though "somewhat reluctantly on the whole," Stream tells HealthLeaders Media. "It was controversial among membership; it was imperfect, and incomplete."

While the AAFP half-heartedly gives its approval of the act, a growing number of physicians seem to be more upset about the law. Surveys and polls conducted periodically over the past two years show doctors expressing a steady and increasing dislike of the reform effort, indicating a widening gap between those who endorsed healthcare reform and those who did not.

In 2011, the year after the law was adopted, a HealthLeaders Media industry survey found that 30% of physicians thought the law was positive, 30% were neutral, and 10% were very negative. Earlier this year, another Health Leaders Media industry revealed that 53% of physicians believe the current state of the healthcare industry is "on the wrong track."

The disapproval numbers are getting higher. A new survey released this week by Jackson Healthcare, a physician staffing firm based in Alpharetta, Ga., shows 68% of physicians disagree that the law will have a positive impact on physician/patient relationships. Only 12% of physicians say the law provides the needed healthcare reform for the country.

In a report, the company says that physicians gave healthcare reform a letter grade of  "D," says Richard  L. Jackson, chairman and CEO of Jackson Healthcare. "It's worse than before," Jackson tells HealthLeaders Media, of physician attitudes about healthcare reform.

"Simply put, they don't like healthcare reform. They don't want to be handcuffed [as to] how they practice medicine. Whether it's real or not, I think they feel they don't want more government control. And I don't think it's just a political issue."

The nearly 2,500-page ACA is so multi-faceted that it is broken down into distinct parts or sections.  Physicians may embrace or reject it in total, but many others may like some of it, or dislike some, with partisan preferences playing a role, Stream concedes.

"Even among this very intelligent segment of our population, physicians, I think many of the folks are subjected to the same sort of partisan rhetoric as the rest of the population," Stream says.

"You can ask them, ‘What part of the Affordable Care Act don't you like? Are you against insurance reforms, such as coverage for young people to 26, or no pre-existing conditions?' They are all in favor of that. Are you in favor of getting more primary care doctors and having them paid more? They say, ‘Yes.'"

Not surprisingly, Stream sees the individual mandate provision of the law, which goes into effect Jan. 1, 2014 and requires virtually all Americans to obtain insurance or pay a fine, as a major sticking point and cause for disagreement among physicians. It will certainly be a prime focus for the highest court.

The Supreme Court is expected to decide the constitutionality of the individual mandate, which also impacts other provisions of the law, including a requirement health insurance companies provide insurance coverage for those with pre-existing conditions. Disagreements are reflected in internal polling of the physicians group, in which 19% showed they wanted a complete rejection of the law, and—at the other end of the spectrum—18% didn't believe it "went far enough" in insurance coverage.

"The (individual) mandate is the one piece that people legitimately have fundamental differences of opinion (about)," Stream says. "The other provisions, I think, pale in comparison. But our policy for 20 years is that everyone should have access to health insurance coverage of some kind. I have not seen anybody making a convincing argument that you can get everybody covered, without a mandate. Is a mandate the ideal thing? No."

So what happens if the Supreme Court doesn't touch the law, or just overturns a few sections, and not the individual mandate? With so many more physicians opposing the law, there is certainly going to be more disappointment spread around.  For some older doctors who hope the Supreme Court strikes down the measure, a court decision to uphold it means they will exit the world of being a provider that much sooner.

Hal Scherz, MD, a 57-year-old urologist in Georgia, who founded an organization Docs4 Patient Care, in part, to fight the law, is adamant that the high court's approval would be a turning point in his career. "My time horizon will truncate," he says, noting that he would quit the profession sooner than he would have anticipated. 

"I love what I do and I could easily practice until my 70s, but I am just fed up with all the government overregulation. They have every intention of slashing more revenue, and with the amount of money spent on liability insurance, at some point it just won't be worth practicing. I may be a consultant, and educate myself in healthcare policy."

Certainly there are other physicians who, like Scherz, are "fed up." Many who don't quit certainly may grumble to their colleagues and to themselves if the law is upheld, or even if parts of it are.

But it's not a time to create "silos" of physician opinion on this matter. As healthcare has shown in recent years, physician teamwork for improved patient care is especially crucial, but it may be even more difficult if the Supreme Court goes against the wishes of many doctors. Indeed, physicians' ability to cooperate may be tested further.

Doctors, like others healthcare professionals, need to look beyond the court action, because there are events and a movement of care that will not remain static, no matter what is written by the court. "A river is flowing toward more efficiency and accountability," says Lucy Savitz, director of research and education of Intermountain's Institute for Health Care Delivery and Research,  based in Salt Lake City, Utah. The group is working with hospitals and physicians to engage in a "culture of continuous improvement."

Stream agrees. Whatever the Supreme Court decision, the health reform law hardly touches many watershed issues such as improvements in medical malpractice laws. Or it completely ignores them, such as the SGR (Sustainable Growth Formula), "which continues to rear its ugly head," Stream says. These overarching issues must be evaluated and considered by physicians, as well as lawmakers, he adds.

"Regardless of the politics and view of the (Affordable Care) act, we recognize there are limitations of our healthcare system," he adds. "We pay too much for too little quality and safety, and we need to do better. There's no doubt about that. There are initiatives for improvement that predate the act, and they are going to move ahead regardless of the Supreme Court action."

For improved healthcare, there can be no languishing in middle ground, Stream says.