It has been two months since the Supreme Court of the United States effectively upheld the constitutionality of the Patient Protection and Affordable Care Act of 2010 (ACA). Since that time, opponents of the bill have been analyzing legislative activity to delay or thwart the ACA’s implementation, while the administration and the bill’s supporters have been working to expedite development of the massive government infrastructure required for the provisions of the bill to function. Unfortunately, the ultimate outcome of this political conflict hinges on the outcome of the upcoming general election; thus, the Supreme Court decision does not provide the finality needed for any sector of the healthcare industry to be on solid ground in terms of long-term strategic planning.

For those of us with administrative responsibilities in large urology groups, the dilemma is amplified by the fact that we are affected not only as providers of care but as employers. The overwhelming majority of our practices have greater than 50 employees; those who do not provide “creditable coverage” will face a $2000 per employee penalty. Presently, this minimum (known as “bronze coverage”) will provide for certain essential health benefits (Table 1) and cover 60% of the benefit costs of the plan, with an out-of-pocket limit equal to the Health Savings Account (HSA) current law limit ($5950 for individuals and $11,900 for families in 2010). Depending on the policies adopted by an individual state, many of us will be faced with the same uncomfortable decision as other small businesses: It may be economically advantageous for us to cease offering health insurance as an employee benefit and pay the penalty, effectively forcing our staff into Medicaid-run state insurance exchanges.

Furthermore, there is absolutely no question that surgical specialists, urologists in particular, do not fare well under the provisions of the ACA. For hospitals and insurance companies, reductions in premiums and/or reimbursements are to be offset by decreases in the number of uninsured patients; insurance companies will have more customers, and hospitals will presumably have to provide less indigent care. As there is approximately $700 billion to be cut from the Medicare program under the ACA, any specialty with a high percentage of Medicare beneficiaries will be disproportionately adversely affected by these changes. As most large urology groups have Medicare populations that account for 45% to 55% of their total patients, these cuts have a potentially drastic negative impact on reimbursements. To be fair, those practices with a high percentage of uninsured patients will obtain some relief, but this is unlikely to offset the losses in Medicare reimbursements. Furthermore, primary care physicians participating in Medicaid-run insurance exchanges are afforded protection under the ACA, as certain codes referable to their specialty are guaranteed enhanced reimbursement; urologists are afforded no such assurances.