Health Care
2:05 pm
Fri November 30, 2012

What Obamacare Means For Patients

Originally published on Thu December 6, 2012 5:02 pm



This is SCIENCE FRIDAY, I'm Ira Flatow. Now that President Obama's been re-elected, it's clear that at least the president won't try to repeal Obamacare. But with all the political mud-slinging about the Affordable Care Act, the details sort of got lost, didn't they? Do you actually know what the law does for you, and just as importantly what it doesn't do, what changes to your health care kick in on January 1, what major changes kick in in 2014 and thereafter?

How are the insurance exchanges going to work, for example? Will insurance actually be more affordable than it is today? Will your doctor still take your insurance? Can you design your own health insurance? And if more people have insurance, will there be enough doctors to go around? Take Texas, for example. It's the most uninsured state in the nation and already has a critical shortage of primary care doctors.

And they prepared for even more people with insurance cards - are they? Could nurse practitioners, community health centers, or so-called minute clinics in your local drug store fill in the gaps? How the changing healthcare landscape is affecting to you, and what to expect from the Affordable Care Act. That's what we're going to be talking about this hour, and you're invited to join in. Our number, 1-800-989-8255, 1-800-989-TALK. You can also tweet us @scifri, S-C-I-F-R-I, or join our website at, ask question there.

Let me introduce my guests. Dr. Marc Siegel is the author of "The Inner Pulse: Unlocking the Secret Code of Sickness and Health." He's also associate professor of medicine at NYU Langone Medical Center here in New York. He's medical director of Doctor Radio and the medical correspondent for Fox News. He's with us in New York. Welcome to SCIENCE FRIDAY.

MARC SIEGEL: Ira, good to be with you.

FLATOW: Thank you. Dr. David Blumenthal is a professor at Harvard Medical School. He's also chief health information and innovation officer at Partners HealthCare and former U.S. national coordinator for Health Information Technology under President Obama. He joins us from WBUR. Welcome to SCIENCE FRIDAY.

DAVID BLUMENTHAL: Thank you, Ira, great to be here.

FLATOW: Thank you. Margaret Flinter is senior vice president and clinical director of Community Health Center, Inc.; that's headquartered in Middletown, Connecticut. She's a family nurse practitioner there. She's also the co-host, along with Mark Micelli(ph) of "Conversations on Health Care," their weekly radio show about health reform and innovations. And she joins us from Connecticut. Welcome to SCIENCE FRIDAY, Dr. Flinter.

MARGARET FLINTER: Thanks so much for having us, Ira.

FLATOW: Let me begin with you. You've been keeping tabs on the law as this kicks in. What changes are already in place, and what changes are set to happen as the clock turns to January 1?

FLINTER: Well, the big changes that are already in place are the pipeline has been increased. Certainly the National Health Service Corps has been increased, the number of community health centers in their capacity to care for people. So speaking directly to the issues you referenced at the beginning, Ira, we've seen increased capacity there, increased training.

The big thing that we're all waiting for, though, and it will be 2014, not 2013, is the development of the state-based health insurance exchanges, and this is a new marketplace where people who previously have been uninsured or not been able to get insurance through their employers are able to go and get that insurance. And I hope we're going to talk about qualitatively how that insurance might be better but also how people who can't afford it will be able to get help in paying for it.

And then of course we're going to see the advent of more preventive services, without co-pays, being able to keep our children, which has already happened, our children on insurance up to the age of 26, because we know one of the biggest groups that were unable to get health insurance were those young people.

And I'm sure Dr. Blumenthal will speak to something that is well underway, that started even before the Affordable Care Act but is supported in it, and that's the increased use of our electronic health records and technology of all kinds: mobile technology, as well as electronic health records, to make care higher quality and safer and more available to people.

FLATOW: Dr. Blumenthal, you're based in Massachusetts, where you already have these insurance exchanges that Dr. Flinter was talking about. How do they work? How do you see foresee any problems with them state to state?

BLUMENTHAL: Well, we do, Ira, have a functioning version of Obamacare here in Massachusetts. It's been in place for five or six years. We have virtually no uninsured individuals, just a couple of percent. There's a very high level of satisfaction among the population here in Massachusetts with the insurance arrangements under our version of Obamacare.

It does rely on a version of the state health insurance exchange. We call it the Connector, and I can tell you from personal experience with patients and with friends that it's very easy to obtain insurance even if you're a poor individual just by going online.

We have not suffered appreciably from a shortage of capacity. We have a large number of physicians in Massachusetts, but we don't have a large number of primary care physicians, and we are working here to improve the supply of primary care physicians. But if you look cross-nationally, as the Commonwealth Fund does, at the reported access to care in Massachusetts compared to other states, you'll find that as many people here report having a primary care or a regular physician as do virtually anywhere in the United States.

FLATOW: Marc Siegel, you've written that Obamacare may be bad for patients and bad for doctors. Why is that?

SIEGEL: Well, I think there's a lot of issues here that we should discuss. The first issue actually Margaret brought up, which is the National Health Service Corps increasing in numbers and the number of federally funded clinics. I find that interesting that she mentions that because I actually think that's a very good thing, but I don't think that that's anywhere near as prominent part of this plan as it should be, probably for political reasons.


I have a lot of concerns about the insurance model here because I think it's based on comprehensiveness. Dr. Blumenthal talks about preventive services, but I'm concerned that it's too easy to overuse this type of insurance. Now, that's not Obamacare's fault. We had that problem before this was extended nationally, meaning if you have the insurance card, if you can find a physician to see you, you can go in to see that doctor even if you don't actually have a medical problem.

That costs a lot of money. And if we cover people with pre-existing conditions, which we should do, but we don't differentiate who's paying more, I'm concerned about people that have self-destructive lifestyles, that get very ill, and essentially they pay the same premium.

I'm glad about covering people up to the age of 26, but a lot of those people would probably prefer a policy that wasn't so comprehensive. So as Obamacare is laid out, and more and more regulations come into play about what kind of insurance is allowed on the state exchange, I'm very concerned about that insurance, not having enough options about what you can actually have, not having high enough deductibles, not having high enough co-pays as a disincentive for overuse of this insurance.

I don't like the one-size-fits-all concept here. I think we need more choices. I think physicians in general have a problem taking insurance. I'm a primary care physician. I continue to practice. Dr. Blumenthal said, you know, there's a shortage in Massachusetts. Well, Massachusetts has more great medical schools than anywhere in the country. What's going to be in North Dakota if we have a problem with primary care docs in Massachusetts?

FLATOW: But this is what we have. I mean the point is, this is - we have Obamacare, and this is where - how are we going to be using it, is the question.

SIEGEL: Well, and that's why we're discussing it today. I think that patients have to be aware of these realities, that it's not rose-colored glasses. This is the law of the land. It is going to be the law. Both doctors and patients have to learn to work with it. But let me phrase my answer a little differently, Ira, so that I address your question directly.

I think we have a major problem with physicians, not just a physician shortage in the United States but physicians who may decide they don't want to work with this insurance. That presents a problem for patients. I'm concerned about that. I'm concerned about a patient that says I have insurance now but I can't find a doctor or a network of doctors to work with it.

FLINTER: You know, Ira, if I could...

FLATOW: Margaret, yes.

FLINTER: Yeah, if I could chime in. I come at this from the perspective of having spent virtually my entire career in primary care and in community health centers and caring often for people who had no health insurance, right? So maybe a little bit of a different perspective. And we say we become experts both in primary care and also experts in trying to organize and arrange care for people who don't have insurance.

So that calls on you to be as innovative and as efficient and to eliminate as many waits and delays and waste areas as you possibly can because your people have very little to begin with. And so we look at the fact that people have insurance for the first time as hugely important. And of course we don't want people to overuse.

You know, my concern is much more underuse than overuse when it comes to preventive services and the like. But it also means in order to make the use, the best use of the resources we have, the physicians in primary care and the nurse practitioners and others, we've got to look at innovations that make a difference.

So we think about things like what happens when my diabetic needs to be monitored four times a year. Do they really need to come into the office, or can we, as I think Marc has suggested he is able to do in his practice, use a combination of email or phone or Skype to help better use the resources we have?

What happens when that same diabetic needs to see a specialist? Can we do that through an electronic consult instead of always sending the person? How do we organize care? How do we bring the mental health specialist right into the primary care office instead of having them across town, where our patients will have so much trouble getting to them and where there's all sorts of inefficiencies in that system?

So it's very exciting to think about once we've leveled the playing field a little bit, where our efforts don't have to go into trying to scramble to find resources for people but can be put into the best use of them, I think we're going to see some really exciting advances.

SIEGEL: If I could - go ahead, David.

BLUMENTHAL: If I could just add a couple of things: This piece of legislation is so incomprehensive and includes so many elements that it's easy to lose track of the big picture. It really consists of two bills within a single bill. One is a bill about extending coverage to people who don't have insurance and making those who have insurance more confident in the ability of their insurance to cover them for things they care about being covered for.

The other, and often overlooked, part of the bill will make major, major changes in the way health care is organized, financed and delivered. There's virtually no aspect of the delivery system which isn't touched by this legislation. So you could focus for a while if you wanted to on the training provisions, which are important, or the community health center augmentation, which is important. But there are also major changes to the way Medicare will function and the way Medicaid will function that are intended to improve the efficiency of care and the quality of care and the value of care received.

Then there are all the coverage-related provisions that include the health insurance exchanges, as well as expansions of Medicaid, as well as guarantees against the termination of coverage by private insurance companies when people get sick and it costs too much, as well as the denial of coverage for people who have pre-existing illnesses.

It's a very comprehensive piece of legislation, and I think it's very easy to get lost in the details.

FLATOW: Well, we're going to get into some of the details when we come back from the break because there are some specifics I think our listeners are already tweeting us and asking questions about. We're talking with Marc Siegel, Margaret Flinter and David Blumenthal about the upcoming changes to Obamacare. So stay with us. We'll be right back after this break.


FLATOW: This is SCIENCE FRIDAY. I'm Ira Flatow. We're talking this hour about the future of health care as the Obamacare legislation laws, now, kick in and start changing things, actually picking up speed in 2013, 2014. I want to bring in another guest, another doctor from Brooklyn. I meant to say, actually, a few months ago a doctor from Brooklyn joined us to talk about his dissatisfaction with the health care system and how he set out to change it in the New York City area.

And joining us now is another doctor with another idea from a different place. He's a longtime practicing physician who's reinventing his practice with the hope of delivering better health care to his patients. Dr. Rob Lamberts is an internist and pediatrician based in August, Georgia. Welcome to SCIENCE FRIDAY.

ROB LAMBERTS: Hello, Ira, thanks for having me on.

FLATOW: You're welcome. Why did you leave your old practice?

LAMBERTS: Well, basically I've been practicing for 18 years, and as time has gone on, as a primary care physician, I've found more and more than my attention has been on focusing on things other than the direct patient care, the direct care of my patients. And as, you know, just to do the same amount of work, I've had - helping my patients, I've had to spend a lot more time dealing with the paperwork, dealing with the details, submitting data to Medicare and complying with the rules.

And I just felt like I was not able to offer as good of care as I wanted to for my patients.

FLATOW: So you've come up with a very streamlined, new system for your office. How - what is your plan? What is your plan?

LAMBERTS: Well, it's called direct care practice, and essentially it's fairly old-fashioned. It's - the patient pays me, and I take care of them, and that's pretty much it. The difference is that it's a $50 plus or minus per-month fee for the patient, pretty much get any service that I give, whether it's over the phone, whether it's over the Internet, whether it's an office visit, whether it's labs that I do in the office.

And this just enables me to offer them care in any way that I can do it. I don't have to bring them into the office for them to come in and see me for every little problem. Because in the old system, the only way that I would ever get paid for something was if I actually saw the patient in the office, and the payment was actually not based on what I did but what I documented.

So this just allows me to focus on giving good care for the patient and not have to worry about the financial stuff.

FLATOW: What about if they need hospitalization and things like that?

LAMBERTS: Well, that would be something above and beyond. That would not be something that would be covered by me. It would be covered by their insurance, whether it's Medicare, whether it's Medicaid or whether it's an insurance plan.

FLATOW: So how does your plan differ from what they call concierge medicine? Although concierge medicine is much higher than $50 a month, right?

LAMBERTS: In general, concierge, it's really more definition. Some people do call this kind of a practice concierge, but, you know, I like to make the distinction is that my goal is not to offer the leather seats and the first-class medicine, you know, the extra bells and whistles that you can get for paying more money.

My goal is to offer as good of health care, which a lot of times is doing less, which a lot of times is just answering questions right then and there when they need to be answered. And, you know, patients will, a lot of times, save up questions for the visit because they know the only time they're ever going to get to interact with me is when they come in and pay for a visit. And so they'll hold on to that.

I want my patients to be continually communicating with me, and concierge does do that, but, in general, concierge tends to focus on premium services and, you know, it can be, you know, 10 times as expensive as what I'm doing, although most of the time it's not. Most of the time it's in the $2,000 to $5,000 per year range.

FLATOW: And what's your view on the Affordable Care Act, Obamacare?

LAMBERTS: You know, a lot of folks saw what I did, because of the timing, as something that was a major comment on the Affordable Care Act. You know, I think the only effect the whole Obamacare thing had on my decision was that it convinced me that I don't think the government's going to fix the problem.

There was so much fighting going on, and really the impact that it would actually have on me as a physician wasn't all that much. If anything, as a primary care doctor, I might get actually a little bit more reimbursement through this because a lot of the focus is on primary care.

But there is, actually, also a provision within the Affordable Care Act that talks about direct care practices and allows small businesses to do a contract with a doctor like myself, as long as I just through all the hoops that I need to, and then a high deductable plan, and then they would avoid the fines that would be associated with that.

So, you know, it - for me actually that's a benefit of the Obamacare or the Affordable Care Act, because it allows me to go out and find these businesses, and I can not only give them coverage and allow them to cut their cost or at least control their cost, but I also can do innovative things like, you know, trying to minimize employee absenteeism, do educational programs at the workplace. You know, I can do whatever I want. Since I'm already paid at the start of the month, it really doesn't matter.

FLATOW: Let me get a follow-up from Marc Siegel. Do you have a comment on that?

SIEGEL: Ira, I think to one extent Rob represents and identifies a certain problem here: a busy primary care doctor who may be being paid less, may not, has more tests, he's worrying about whether they're going to get approved, more and more paperwork. He ultimately will decide - not Rob - but he might decide to see more and more patients to keep his bottom line and keep his office lights on, to keep his practice going.

You brought up something in the middle of Rob talking that I think was really crucial, which you may not realize, which is the hospital may decide that they don't want to work with Rob. They may want to work only with people in-network that actually take Obamacare. So his solution, not only in terms of hospitalization, but in terms of networks, may be problematic.

It may work for him, but he might not find the orthopedist he needs. I've got to tell you, in New York City, I'm not going to be able to work like Rob is going to be able to work. I'm not going to have the doctors I need to work with outside of Obamacare. If I say I'm going to take cash, I'm a great doctor, here's my business solution, I might not have the hospital or the doctors to work with.

But within Obamacare, if I didn't have other sources of income like Fox News, like Doctor Radio, I might find myself seeing more and more patients in a shorter period of time, hiring nurse practitioners. Now, that may be the future here, but that's not exactly the way it was presented to the American public.

FLATOW: All right, good luck to you, Dr. Lamberts, and we'll keep track of how it works out for you. Thanks for joining us.

LAMBERTS: And thanks for having me.

FLATOW: 1-800-989-8255 is our number. We're talking about the future of health care. Margaret, let me ask you for some advice here. What was your opinion of what Dr. Lamberts was working on?

FLINTER: Well, I think that one of the common themes that you're hearing here, Ira, is: One, a need for innovation, and there's plenty of that out there; and two, a desire for people to be paid for the value they're providing and not just the volume of care that they're churning out. And the third is that for us to do everything that we know needs to be done for patients, to do the best evidence-based health care - whether that's at the primary care level, or it's at the tertiary medical center - it takes a lot of time, and, to be honest, it takes a lot more than all of us providers.

You know, we look at the - one of the most promising innovations that's not necessarily spelled out in the Affordable Care Act, but it's implicit there, is the use of the team and the primary care team. And my colleagues might disagree with me on whether this is the way it works in their practice, but for us to have our medical assistants be trained to the highest level we can train them so that that which can be done automatically is done automatically - your screenings for cancer, the preventive tests, the assessments of how well-controlled your asthma is, screening for depression - that doesn't need to rely on the primary care provider always.

That can be done by somebody else, again eliminating some of that time that is so precious in primary care. So, adding to the team, nurses who can coordinate the care of patients. And when you ask, you know, what are - what's the American public going to see that's different, they're not going to see all of the things that are different because of the Affordable Care Act, but behind the scenes, the intense focus that we're putting on helping people coordinate their care and manage transition.

I don't know if you've had the experience of maybe a relative or an elderly parent who's been in the hospital, comes out, doesn't understand anything, everything gets confused, they're back in the hospital in 20 days. The Affordable Care Act takes that head-on and says, you know, it's just possible we can reduce suffering and reduce costs by better care, better quality care, coordinating care more tightly.

And so in our primary care teams, you'll find not just the physicians and the nurse practitioners and the medical assistants, but you'll find our primary nurses really focused on care coordination. And you'll find, thanks to the electronic health record, that they'll have data to use to make that quality better that really I could only dream of when I was first in practice. So, a lot of changes.

FLATOW: Let me ask one thing that people are going to notice, and that's their insurance premiums. Are insurance premiums going to be any cheaper for people through the exchanges? And as a tweet comes in here, says: Will I have a choice of what insurance policies I would like to take - about these exchanges? Yeah, if you'd want to jump in there.

SIEGEL: Let me respond to that. There isn't going to be such a thing as Obamacare and being in it or out of it. What Obamacare chiefly does on the insurance side is make it possible for people to buy private insurance that is equivalent to what they would get if they had a reasonably complete private insurance plan through their employer. What it does is really enshrines and reinforces and supports the private health insurance market that has existed for 67 years in the United States. So...

FLATOW: All right. Let me ask a practical - let's go through a practical setup here. It's now 2014 and I want - I can buy my own insurance. What do I do? Do I go online? Do I have to find a broker? How does that all work?

BLUMENTHAL: So you go on - let me describe a very practical experience that I witnessed. A friend who developed a brain tumor didn't have insurance, went online in Massachusetts to the Connector, had 10 or 12 choices of different insurance plans, enrolled and had insurance within a couple of weeks. It would have been totally impossible for that person as an individual, not part of a group, to have good solid private insurance with no restrictions, no pre - no exclusions of pre-existing conditions - that, and had a choice, not one plan but multiple plans.

The insurance exchanges are going to be required to offer multiple levels of insurance, including a catastrophic plan. There are no - there are restrictions on the amount of deductibles, but deductibles are possible. There are restrictions on the amount of - that individuals will have to pay out of pocket that are somewhere between two and nine percent of their income, but there will be premiums paid. So it's a kind of friendly version of the current private insurance market we have. It will be like going online to buy an airplane ticket or to register - or reserve a hotel room, with easy comparative data, so...

FLATOW: What about the states that do not want to create the exchanges? Where do the people of those states go?

BLUMENTHAL: So there will be an exchange in every state. It will either be run by the state, or it will be run by the federal government.

FLATOW: So they'll have a choice of going to the federal government if the state doesn't...

BLUMENTHAL: The federal government will have an exchange that will be run under federal auspices that will be available to members of that state. There are also versions of a federal/state partnership that will be possible. State may run part of the exchange but not all of it.

FLATOW: Can the state compete with the federal government in a different exchange and get a better price, or can the federal government just, you know, vice versa? Will it be competitive pricing?

BLUMENTHAL: Well, there will not be a federal exchange and a state - parallel state exchange in the same state. There will be one exchange. It will either be run by the state, or it will be run by the federal government, or it will be run by a federal/state partnership.


FLATOW: Let me just interrupt and - we have to pay the bills too. This is SCIENCE FRIDAY from NPR. OK. Let me first go to - because I know that you (unintelligible)...

SIEGEL: OK. A couple of comments on what's been said, some of which I think is very inspiring. In terms of the states, what he - what David just said about the exchanges, the one exception right now may be Utah, where they're trying to set up a voucher program which won't be approved unless they campaign for it and say, look, I want an alternative here to the state or federal exchange. Second point is, I'm concerned and other critics of this are concerned that the premiums are going to be too high because there may not be enough choices because these are state exchanges rather than federal exchanges.

Third point, I don't really believe that young people who actually constitute most of the uninsured are going to have enough options in terms of catastrophic only. Next point, Margaret's point about quality of care in teams, I love that. I hope it works. I think she made a really brilliant point to bring that up. We have to go in that direction. I'm not against that. The question is, though, can quality of care really be reinforced as the accountable care organizations are going to try to do when you consider - my view is if you're a criminal as a physician ordering too many EKGs, you're going to be a criminal under accountable care organizations trying to fake some paperwork.

I hope I'm wrong about that. I hope fraud and abuse is decreased, but her idea of a system of doctors and nurses and care providers that actually don't only have money as a bottom line but care for the patient - inpatient and outpatient. Now, one final point that may undermine this - you know, the current penalty for readmitting a patient to a hospital if they have the same diagnosis, which ironically would apply today probably to former president George H.W. Bush, who has been readmitted for a recurrent bronchitis.

I don't know if his hospital will actually be reimbursed for that, because he had that two weeks ago. But humor aside, I think that that penalty doesn't take into account the problem we have with rural areas where you may not be able to get out of the hospital and get to a primary care doctor. Again, this isn't all Massachusetts. So why should a hospital be penalized for a readmission?

FLATOW: 1-800-989-8255. Let me get a quick phone call before the break. Amin(ph) in Birmingham, Alabama. Hi. Please turn down your radio. Turn down your radio. Amin. Oh, got the drop on there because - let's go to - well, let's go to John in Wichita. Hi, John. John, are you there? Well, we're having trouble with the phones today.



FLATOW: Well, he's going to - his question was: How will it affect - how will the exchanges be affected by union contracts that are already in existence? Will they be grandfathered? How is that going to work, David?

BLUMENTHAL: If you have insurance currently - sometimes people have insurance through their unions. Sometimes they have them through their employers. If you have insurance currently and you want to keep it, you will be able to keep it. That's one of the key tenets of the Affordable Care Act. There - but insurance obtained through the workplace will continue to be obtained in the same way that it already has. That is, it will be a subject of collective bargaining. One of the advantages of Obamacare is that if an individual becomes unemployed, let's say they were to go on strike, as an example, they and their insurance were to lapse, they could get insurance through the exchange in - as an individual, which would have been much more difficult before.

FLATOW: Quickly, before the break, David, what about all these electronic health care records? Are - is one hospital going to be able to read the other ones? Are they going to be compatible?

BLUMENTHAL: We will soon be able to provide that service. That's already now available in Massachusetts, not because of our comprehensive health reform but because of progressive leadership from the community here and from the state. The national government, the federal government has created the wherewithal for what's called interoperability in which electronic health records talk to one another. The technology is available. It needs to be accepted and implemented by providers of care. They have the capability to do that. They just have to take the initiative.

FLATOW: All right. We're going to take a break. We'll come back and finish up the hour talking about health care. Our number, 1-800-989-8255. My guests, Dr. Marc Siegel, Dr. Margaret Flinter and Dr. David Blumenthal. You can also tweet us, @scifri, S-C-I-F-R-I. We'll try to dig down into some more of the details of the changing health care law as they're going to happen in '13 and '14. So stay with us. We'll be right back after this break.


FLATOW: This is SCIENCE FRIDAY. I'm Ira Flatow. We're talking about the future of health care, the health care act we lovingly call Obamacare. We're not (unintelligible) but it's what everybody calls it, so we call it also. With Dr. Marc Siegel, author of "The Inner Pulse." He's also an associate professor of medicine at NYU Langone Medical Center in New York and the medical director of Doctor Radio here and medical correspondent for Fox News. Margaret Flinter, senior vice president, clinical director of Community Health Center in Middletown, Connecticut. She's a family nurse practitioner there. Dr. David Blumenthal, professor at Harvard Med School, also chief health information and innovation officer at Partners health care. He's the former U.S. national coordinator for health information technology under President Obama. Our number, 1-800-989-8255. You wanted to make a case, make a point, Marc?

SIEGEL: I want to throw something back to David, who by the way is one of the world experts on health information technology. First point - I have a two-part question for you, David. First point, your friend and my friend, Dr. Jerry Groopman, has pointed out that health information technology may not be that efficient for several years. It may not actually save money. The second point is, what about competing institutions? Because we're concerned that unless there's really a national database that actually comes into play, people are going to get very territorial Oh, you can't go to that hospital because we have all your information at our hospital, and you can't...


SIEGEL: ...get it at the other hospital.

FLATOW: There are competing systems.

SIEGEL: How are we going to resolve that in the near term?

BLUMENTHAL: That's a great question and - we've been talking here about not electronic health records per se but their ability to talk with one another or exchange information, and that's absolutely a vital ability of electronic health records. I'd point out that there's never going to be an opportunity to exchange information unless it's in digital form, so that in order to have exchange, you have to have electronic health records. The question then is how to get the information moving across organizations.

And health information exchange is a team sport. You can't do it by yourself. You have to have a receiver down the field. If there's no one who wants to catch your information or to send it back to you, you're out of luck. This is a community problem that is inhibited by the economic incentives that cause competition in our local health care systems that do not value the quality and efficiency of care and do not reward people in the business of providing care for coordinating care, reducing its cost and improving its quality.

One of the most important aspects of the reforms that will take place, if we're lucky under Obamacare, or under the Affordable Care Act, is it puts in place a whole bunch of incentives to make care better, and those incentives will have, if they are fully enforced, the - will create a will and a business case to use electronic health records to exchange information.

But the records won't do it, unless the people want to use them to do it.

FLATOW: Will - Margaret, will it also encourage people to eat healthy, to exercise, stop smoking, things like that?

INC.: Well, that's, of course, the holy grail, right? Because everything that we do in health care is - only pales in comparison to what consumers and people can do, what parents and children and families can do by better and healthier lifestyles. But you know, the Affordable Care Act does have a provision to help with that. It's called the Community Transformation Grants, where community people come together, such as people - one of my favorite examples is the city of Somerville, Massachusetts, to really make a healthier environment for everybody in the community for all those things that happen outside of health care, particularly around safe streets, good housing, nutrition and physical activity.

But you know, Ira, if I can just speak to two things quickly, one, just totally agreeing with what's been said about the electronic health record. We've been on a fully electronic health record for six or seven years now. That is transformative in health care. But the other group of people that we haven't really talked to, two groups that I just want to make mention of is one group that won't be addressed at all and is not address at all in the Affordable Care Act, and that's the folks living in the United States who are undocumented, which as we know are large numbers of people who don't get addressed in the Affordable Care Act at all.

But the other that will have a better time of it, I think, are our lowest income citizens, and that's the folks who for the first time now when people go to the exchange to apply for insurance, the technology will be there to screen them for eligibility for Medicaid and the limits under which people can qualify for Medicaid will have been increased, at least in most states, to 133 percent of the federal poverty level. And again, when you're talking about the people I've cured for all these years, people who have not had any insurance having insurance, that's huge. And of course we worry about the ultimate cost of all insurance. And I was very happy to see the medical law issue addressed where 85 percent of the premium must be spent on health care.

FLINTER: And also you can't just do a 20 percent increase to the premiums anymore. There are some reviews and some ceilings to go with that. So thanks for letting me make those viewpoints too.

FLATOW: Good points. So let's go to Mark in Chapel Hill. Hi, Mark. Welcome to SCIENCE FRIDAY.

MARK: Hi. Thanks for taking my call.

FLATOW: Go ahead.

MARK: I think the elephant in the room is whether or not the profit margins in the medical industry are sustainable. Some of this discussion is always focused on patients doing with less care. What about the medical profession do with a smaller profit margin? I have a builder friend who complained that he was losing money on houses he built because he only made 50,000 instead of 80,000. In his mind, he lost 30, but he actually made 50. Is there any discussion about maybe reducing the profit everyone takes?

FLATOW: So you're saying that doctors are not going to buy into this, or are against this, because they're going to be losing money for (unintelligible).

MARK: That's what I hear. I hear that a lot about how...

FLATOW: All right. Well, let me get some...

MARK: Physicians are losing money.

FLATOW: Let me get some answers. You want to bring that up?

SIEGEL: I think that brings the point up about specialists 'cause I've been talking mainly about primary care docs, which I am, and what I'm concerned about exactly what the caller is saying - that specialist surgeons that put all this time into their training and have this, basically, they're more on a market situation. You want my service? You want my robotic prostate surgery? You want my skill that no one else has? You're going to have to pay for it. Psychiatrists, as well. I think those people are going to go more and more outside the system and take cash only, and that undermines the whole idea of insurance expansion.

FLATOW: David, do you agree?

BLUMENTHAL: Well, physicians in the United States are well paid. It's an attractive profession. I'm really not worried that if we reduce the rate of increase in physician compensation that we will lack for physician supply. I actually have two children who are training to be physicians, and I don't see any reduction in the interest in the medical profession. So I think that there probably is a case for reducing the rate of increase in physician compensation, over time, and hospital revenues, over time.

I think that's coming. I think it's almost inevitable. It's part of the debate that we're having in Washington right now about the fiscal cliff, because a big part of our deficit is attributable to increases in the cost of health care, not only through Medicare and Medicaid, but in the military service and the veterans administration throughout.

FLATOW: Let me go to Jackie in Illinois. Hi, Jackie.

JACKIE: Hi there. Thank you for taking my call. It's a pleasure.

FLATOW: Mm hmm.

JACKIE: I am a 27-year-old, so I'm, kind of, in that gap of young people that have missed out on insurance. And I live in a rural community on a pretty modest income. And I have had no medical insurance and suffered from (unintelligible) mal seizures for the last four years. And I'm concerned that when Obamacare happens, when it goes into effect, that I will be in a place where I can't afford medical insurance, but I also can't afford to not have medical insurance because I'll be paying to have insurance and, you know, or being forced to pay to not have medical insurance. I'm just curious what you have to say about that.

FLATOW: Margaret Flinter.

FLINTER: Sure, I'd love to answer that. And, you know, first, of course, you need really good health care just for your preventive health care, but also because you've identified that you have a health condition that requires ongoing monitoring and treatment. So I would say you want to go to - and this is a great primer - the Kaiser Family Foundation allows you to, kind of, simulate what it's going to look like when you go to the exchange and you are able to put in your age. And you're young, and that's one thing that will have a lower premium, but also your income and your family size, and we'll tell you how much of a subsidy you'll be eligible for.

And if you're under 400 percent of the federal poverty level, and I know that number doesn't mean anything to people as an obstruction, but you can find the information there, you're eligible for pretty hefty subsidy. I think of it like a sliding fee scale. And I would encourage you to do that, and I'm hoping you'll find that it is affordable. And, of course, coming from the community health center world, I always encourage people, also, to look up on - - find a health center near you. And if you put in the county you live on, you can find a source of care on the sliding fee scale basis.

FLATOW: And what year? Do that kick in '13 or '14?

FLINTER: 2014. January one, 2014.

FLATOW: So, Jackie, you have to wait till 2014.

SIEGEL: I happen to see...

JACKIE: That's alright. Then four years.

FLINTER: Look for a community health center sooner.

SIEGEL: Ira, I happen to think that her specific case, over the age of 26, but she can't go on her parents' policy. She actually speaks for what's good about — one of the thing that's very good about Obamacare. She has a preexisting condition. Margaret's right, she can get a subsidy out of exchange. She may very well end up covered, whereas before, she would've been in big trouble. I think it's - this specific group will be helped.

FLATOW: Hmm. Margaret, we have only about, like, a minute or two left. What are the milestones that we should expect coming up, beginning of this year and through the year, and then next year?

FLINTER: Well, again, I think the milestones are happening on two levels. One is the development of the state-based health insurance exchanges or market places. I'm proud to say here in Connecticut, we're kind of at the front of the pack, that they have an enormous amount of work to do to build the technology, to do that screening, figure out the subsidy. That the plans that will begin because the insurance plans have to meet what's called the essential health benefits, which we haven't talked about, which just means it's good high value insurance.

So that's going to go on all throughout this year. But the second piece that's running underneath it, is the development of all the innovations and the models. And I don't think those are so much time based as they are innovation based, where people are developing the accountable care organizations, and the care coordination strategies and the alternative delivery systems as well.

FLATOW: Well, I'm going to thank you all for taking time to be with us today. Certainly, we could talk for hours about this. And we probably will as the health care system rolls out. Thank you, Margaret. Margaret - Dr. Margaret Flinter, senior vice president and clinical director of Community Health Center in Middletown, Connecticut. She's a family nurse practitioner there. She's also co-host of "Conversations on Health Care," a weekly radio show about health reform and innovations.

David Blumenthal, professor of Harvard Med School, also chief health information and innovation officer at Partners HealthCare, former U.S. national coordinator for health information technology under President Obama, and Dr. Marc Siegel, author of "The Inner Pulse." He's also an associate professor of medicine at NYU Langone Medical Center here in New York. He's medical director of Doctor Radio, which you can hear on satellite radio - Sirius Satellite Radio. Also, he's medical correspondent for Fox News. Thank you all, for taking time to be with us today.

BLUMENTHAL: Thank you.

SIEGEL: Thank you.

INC.: Thanks, Ira, for having us.

FLATOW: I'm Ira - you're welcome. Good luck to you all. I'm Ira Flatow. This is SCIENCE FRIDAY from NPR. Transcript provided by NPR, Copyright National Public Radio.