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Former AMA president sees Affordable Care Act successes

Dr. Nancy H. Nielsen served as president of the American Medical Association at a time when lawmakers, lobbyists and representatives of the health care industry engaged in extensive, high-stakes negotiations over what became the Affordable Care Act.

Nielsen, a board-certified internist from Orchard Park, has served as an administrator at the University at Buffalo School of Medicine and Biomedical Sciences for years before and after her 12-month term at the helm of the doctors’ group in 2008-09.

Now a senior associate dean at the school, Nielsen continues to closely follow the progress of federal health care reform, which remains deeply controversial.

Stephen T. Watson: The Affordable Care Act sought to expand coverage to the uninsured, reform the insurance industry and slow the rise in health care spending in this country. Has it succeeded?

Nancy H. Nielsen: The expansion of coverage is undisputed. It should have been higher, except for the Supreme Court decision on Medicaid expansion. But even with that, there are millions more Americans who now have coverage than before. So that goal has been partially met. The goal of insurance reform has in fact been met, in large measure. Now, the insurers wouldn’t respond that way. But from a consumer’s standpoint, you can’t deny that letting your kids be on your insurance helps a lot of young people who are uninsured and in between jobs. You can’t deny that allowing people with pre-existing conditions to access health insurance helps. So I think those two goals have been met. The issue of affordability, we’ll see. Because there has been a cost-shifting to consumers, and everybody knows that. That is a trend that probably won’t be reversed, and so that is going to be an interesting one to watch. The overall, upward trend in medical costs, has been bent, maybe before the Affordable Care Act actually was fully implemented.

SW: The Hobby Lobby decision found that closely held companies with religious owners aren’t required to provide insurance coverage of contraceptives to their workers. How significant is this ruling?

A: It has just spewed a series of more attempts for employers to evade that expansion of preventive benefits. And so how widespread will it be? There’s two parts to that. Will it go to things other than contraception? I don’t think so; I think it was pretty narrow. The Supreme Court said don’t try to use your religious convictions if you don’t like transfusions, and you don’t like vaccinations, don’t try to use this. It does not apply to that. So I think it will remain narrow, but what we’ve already seen is hundreds of employers trying to get out of that. So will all employers try to get out of that? No, because women are not going to tolerate that.

SW: What do you think of the growth of the Buffalo Niagara Medical Campus?

A: This is an extraordinary opportunity that comes maybe once every 50 or 100 years, to converge interests and institutions into a unified vision of what we want in terms of health care for this region. So what’s happening with the Buffalo Niagara Medical Campus, Roswell [Park Cancer Institute], and the new medical school and the new Children’s Hospital, all of these things are not just revitalizing the economy downtown, housing as you know, and restaurants, and all the things that are going to happen. But if we do it right, if we can align the interests of people who are sometimes natural competitors, we can change health care delivery in this region in a way that will transform it into a real, world-class destination for health care. That is the vision.

SW: We’re facing a shortage of primary care physicians. Why don’t more medical students want to practice in this field?

A: The first answer you’ll always get is primary care is paid poorly compared to procedural specialities, and that is true. But having counseled medical students for 13 years in terms of career counseling, and understanding what motivates them, it isn’t just that. The reason is that young people are looking at a work-life balance. People are looking for more stability. They want to be employed in an organization where they can have an impact and practice good medicine but not worry so much about the business. So you’re seeing people who see the opportunities to practice in a way that is controllable and allows them to live the life they want to live. Easier to do in a narrower specialty than in primary care because there’s so many demands on primary care.

SW: What can the government do to encourage more young doctors to practice in underserved regions of the country, such as upstate New York?

A: You have to incentivize people to go there, and stay there. So there are ways to do that. You can do it by loan forgiveness. You can do it by salary guarantees for a period of time. The problem with the rural areas is you’re isolated. People want to go to the theater. They want to go to the movies. They want to drive to six different grocery stores. And they want a hospital that’s close by. They don’t want to be the only game in town with no coverage, on call every day of the year. So it is really a problem. Rural areas are very concerned. What is probably going to be a big help is increased use of technology like telemedicine, because then you’re not isolated.

SW: What do you think of the federal government releasing the prices charged to Medicare by physicians and hospitals for common procedures?

A: There are excesses that this data dump from Medicare revealed that are stunning, like the ophthalmologist in Florida who had chosen to use the very expensive drug to treat macular degeneration instead of the cheaper drug, made by the same company, which works just as well. And they are making a fortune on that. And it reveals things like, there were OB-GYNs who were the highest billers for group psychotherapy. Really? How could that happen? It shines a spotlight on anomalies. And sometimes the anomalies are a business contract, which can be explained. But sometimes they needed to see the light of day, and I’m all for it.