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Effect on patients, doctors, insurers, costs starts in 2014

WASHINGTON – Don't expect anything different at the doctor's office anytime soon following Thursday's Supreme Court ruling upholding President Obama's signature health care reform law.

But over the course of the next few years, everything – from who you see at the doctor's office to who provides your insurance to how much you pay for it – could change.

And if you don't have health insurance now, you face the biggest change of all. Starting in 2014, you will have to either buy coverage or pay a federal penalty.

Those were the main conclusions that medical professionals in the Buffalo area reached after the Supreme Court's decision upholding the Obama health law.

Many health care providers breathed a sigh of relief after the court ruling, not because they support the law wholeheartedly but more because they think more confusion would have ensued if the law had been overturned rather than upheld.

"We've gone through two years of political theatrics, and now, finally, we get to Act 2 of the play," said Joe McDonald, president of Catholic Health in Buffalo.

Buffalo-area health care providers have spent the last two years trying to learn about and adjust to the law, a hugely complex remaking of the American health system that has only started to take effect.

Some of the popular elements of the bill, like the one allowing people to keep their children on their health policies until age 26 and another reducing prescription costs for the elderly, are already at work.

But the central provision – the "individual mandate" that everyone have health care insurance – won't be implemented until 2014. Medical professionals say that will be the real game changer, even for people who already have insurance.

That's because upwards of 30 million people who are now uninsured will start getting health care on a more regular basis.

And as a result, primary care physicians in Buffalo and nationwide will suddenly find themselves coping with a new influx of patients.

"When you insure everyone, you wake up the next morning and say, ‘We don't have enough primary care providers,'?" said Dr. Tom Rosenthal, chairman of the Department of Family Medicine at the University at Buffalo School of Medicine and Biomedical Sciences.

Local health care providers offer differing opinions about what that will mean.

Some say it will be increasingly difficult to find a primary care physician if you don't have one already. Others say it will mean that if you have a doctor, it might be tougher to get an appointment – or that you will get an appointment with a physician's assistant instead.

"There will be a greater reliance on ‘extenders,'?" health care professionals who work with doctors, said John E. Bartimole, president of the Western New York Healthcare Association. "You may not see your personal care physician as much."

Eventually, though, the local health care system is likely to adapt, with medical schools providing more general practitioners to meet the need, Rosenthal said. That's what happened in Massachusetts, which installed an individual mandate in the mid-2000s.

Meanwhile, vast changes are likely to occur throughout the medical field.

The bill's emphasis on "Accountable Care Organizations," which team up with medical professionals to work together to provide coordinated care, could end up slowly moving the nation away from the old – and expensive – fee-for-service model of medicine.

And a controversial "Independent Payment Advisory Board" under Medicare will evaluate and promote the best and most cost-effective treatments, in effect setting national health care standards, Rosenthal said.?"The United States has never had a national standard for care," which is common in other countries, Rosenthal said. "I think this is essential."

It's also essential to understand that health insurance could change over the years under the health law as well.

The law forces states to create "exchanges" where those without insurance will be able to comparison-shop for coverage. In effect, it's giving the uninsured the kind of insurance choices that so many people get during "open season" every fall.

And while big employers are likely to keep those insurance options in-house, Dr. Michael W. Cropp, president of Independent Health, wonders if smaller employers will stop offering insurance and simply give their employees a subsidy they can use to buy policies on the exchanges.

"They may just say: Here's a defined contribution, now go shop," he said.

How much will insurance cost as a result of the Affordable Care Act?

That's one of the biggest remaining questions, and it will likely depend on whether you have insurance now.

The bill includes a tax that could amount to $350 or $400 on existing policies, a cost that insurers would have to pass along to their customers, said Donald Ingalls, vice president of governmental affairs at BlueCross BlueShield of Western New York.

"We are concerned about that," ?Ingalls said.

Then again, for those people who have to buy insurance on their own and not through their employer, prices are likely to go down thanks to the exchanges, the first-ever competitive markets for such insurance customers.

"I do think you're going to see the rate trends flatten out," Cropp said.

Another big question, though, is how many of the uninsured will actually buy insurance once the health law takes full effect in 2014. The Congressional Budget Office estimates the annual penalty for those who don't have insurance to be around $1,000, far less than just about any health insurance policy costs annually.

New York has proportionately fewer uninsured residents than many other states, partly because of the state's traditionally generous Medicaid program for the poor.

Over the past decade, New York, under both Republican and Democratic governors, has dramatically expanded Medicaid for such people as low-income adults without children. Eligibility for Medicaid services kicks in far earlier than in many other states, and New York has even eased application procedures to encourage people to sign up.

That being the case, the state is expected to go forward with a further expansion of Medicaid under the Obama health law, even though the high court overturned the harsh federal sanction for states that do not agree to expand their programs.

"For us, it's not a cost. We're going to get a rebate" from the federal government for adding more people to the Medicaid rolls, said Elizabeth Benjamin, a Medicaid lawyer at the Community Service Society of New York, a nonprofit advocacy group. ?"We only stand to benefit and benefit massively, so there's no reason why New York shouldn't go forward."

The state, and the Buffalo Niagara region, will benefit massively in a much more important way if everything goes right under the Obama health law, Bartimole said.

More people will be getting health care when they need it, and not waiting until they have to go to the emergency room, meaning they will get cheaper and more timely care, he said.

"It means a healthier Western New York," he said. "I have no doubt of that."?

Tom Precious of The News Albany Bureau contributed to this report.