The Supreme Court’s ruling on the Affordable Care Act set off a steady stream of local reaction Thursday with lawmakers calling for the bill’s repeal, health care providers scrambling to implement its provisions and residents expressing relief and doubt about the law’s sweeping health care reforms.

U.S. Sen. Ron Johnson, R-Wis., whose opposition to the bill inspired him to run for office in 2010, lamented the court’s decision, but said it will energize Republicans ahead of the November presidential and Congressional elections.

"I guess from a practical standpoint of elections, our base is certainly going to be energized by the challenge facing us now that the Supreme Court didn’t invalidate the law," Johnson said during a teleconference with reporters Thursday. "So now we have to work on it in the political world, so I think it energizes our base. But again, I don’t say that with any joy. I wish the health care law would have been repealed or stricken down."

University of Wisconsin-Oshkosh Associate Professor of Economics Chad Cotti said the act’s key provision - requiring everyone to purchase health insurance or pay a fee - should increase the pool of people who fund medical care and thus reduce the costs everyone has to pay for services. He said Republicans originally developed and supported this approach to health care reform in response to President Bill Clinton’s efforts to develop a government option in the 1990s. 

"The idea is people develop a sense of personal responsibility in paying for their insurance. And it provides for a bigger pool, and bigger pools mean lower costs," Cotti said. "You’re spreading the average cost across a larger, healthier population."
He said Americans who are already insured will likely see few changes once the major provisions of the act take effect in 2014. 

"The reality of the ruling today is for the majority of Americans, the people who work and have jobs, will not be affected by the Supreme Court’s ruling," Cotti said. "The employers are going to face a penalty, a tax, if they don’t provide this service. It’s a pay or play law. Firms will either participate by providing health insurance, otherwise there will be some sort of tax on them."

Oshkosh resident Bill Bracken said he was surprised by the court’s decision, especially the decision to uphold the individual mandate. He favors letting individual states deal with health care issues, citing Wisconsin’s ability to hold down the number of uninsured residents in recent years. 

"There can be standards set, but a lot of it will be based on how states deal with the issue," Bracken said. "The federal government is coming in and saying one size fits all when it doesn’t."

Oshkosh resident Colleen Olson said she thinks it was good the law was upheld, but wants to wait and see what comes of it. She said she’s been uninsured for five years and wants to learn more about federal subsidies included in the act to help low income individuals.

"I’m thinking it could be a good thing, but only time will tell," Olson said. "I was very surprised it was upheld. I didn’t think it would be. I’ve heard so many negative things about it."

Ron and Diana Underwood, a Sheboygan couple visiting Oshkosh for Waterfest, also said they were pleased to see the law upheld and hope President Barack Obama spends time on the campaign trail clarifying what the bill aims to accomplish.
"I think the more they learn about the bill, the more people will find parts of the bill they like, as opposed to parts they don’t like," Diana Underwood said. "The president needs to make it clear what the bill does so people understand it."

Oshkosh resident Jon Hatch said he's not so sure the bill will make it easier for the poor to secure insurance. Hatch, who did not have insurance at the time the bill was proposed, said he sees the mandate to buy insurance as something that would put people who can’t afford the cost in an even tougher position. 

"I don’t like the idea of either having to pay a penalty for not getting insurance or buy into a plan at inflated rates," Hatch said. "In the end, it's like you're applying a new tax on the poor. They can’t afford insurance and they’ll be asked to pay for it or pay the fine."

Election, reform issue

Rep. Tom Petri, R-Fond du Lac, said it is likely that serious consideration of a repeal will have to wait until after the November elections, since the current session is quickly coming to a close. He supports efforts to repeal the act and favors replacing it with wellness initiatives and cost-controlling measures similar to ones ThedaCare’s Center for Health Care Value has started to test out. He said he would like to see changes in the way health care providers are reimbursed.

"It’s not just looking at insurance and that side of it, but looking at the delivery system and trying to change incentives for the health care delivery system," Petri said, adding that some area health providers are exploring what’s known as a wellness model. "(Wellness models) basically undertake to pay any expenses that you have or provide any care that you need, but they concentrate on working with employers and families on keeping you well, so you don’t get to the point where you have to do these operations. They feel there are real opportunities for improving quality and doing a better job of controlling costs."

ThedaCare Center for Health Care Value CEO Dr. John Toussaint said his agency pre-dates the Affordable Care Act, but it has begun to work with the Center for Medicare and Medicaid Innovation, an agency created by the ACA, on programs to cut out unnecessary procedures, reduce costs and make health-care performance transparent to consumers. 

Toussaint said health-care organizations in 27 states and six Canadian provinces are trying to apply lean principles popularized in the manufacturing industry to health-care systems. He said the programs look to eliminate wasteful procedures and programs in order to cut costs without sacrificing the quality of care. 

"We simply cannot afford the massive waste that exists in the industry today," Toussaint said. "Some estimates put it as high as 40 or 50 percent of what we do is waste. In a $2 trillion industry, that’s a lot."

He said many of the pilot programs have only been in place for six months and might have been threatened if the Supreme Court struck down the law. 

"The point is the innovation center, now that the bill has been upheld, will stay intact and these programs will move forward, which I think is a good thing. It’s a lot of hard work, but it can be done," Toussaint said. "I think (closing the Center for Medicare and Medicaid Innovation) would have been a blow to the work we need to do to determine how to pay for value in health care."

ThedaCare CEO Dr. Dean Gruner said providing services to patients is about the only element of the health care system untouched by the law.

"The direct impact of the legislation is on insurance companies, individuals and employers. The indirect impact is on health care systems like us," Gruner said. "We will be downstream of the impact. We’ll have to manage new rules and regulations, but the care we directly provide to our customers is not impacted."

He said ThedaCare has sought ways to reduce costs and improve care since it started to adopt lean principles in 2003. 

"Our real focus is to improve the health of the community and deliver increased value in health care to the people we serve," Gruner said. "I don’t want people to get so interested in politics and Supreme Court decisions that they take their eye off the ball: Improving health and increasing value to our customers. We believe that’s what our community expects of us."

The Congressional Budget Office projects the ACA will cut $125 billion from the deficit over the next 10 years, but Cotti said any savings will depend on how the government administers the programs once they take effect. 

"It does seem like it will save the government money based on the CBO’s estimate and taxes should come down. But the government’s ability to maintain and manage something like this is up to legislators."

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