Last Monday, Amy Coney Barrett’s confirmation solidified a 6-to-3 conservative majority in the Supreme Court of the United States (SCOTUS). Reputed a conservative jurist who has disagreed with certain aspects of the Affordable Care Act, Barrett is set to hear her first case beginning on November 10. The case challenging the constitutionality of the ACA, leaves many worrying about the fate of the comprehensive health care reform law.

The effects an ACA repeal would have on patients are apparent. About 20 million people who gained access to health insurance under the federal statute will stand to lose it if the appeal goes through. This will be particularly devastating during a pandemic, when healthcare services are needed more than ever and many have lost their jobs and thus employer-provided insurance. Further, the long COVID medical sequelae can linger for months, becoming a pre-existing condition that insurance companies may use to deny coverage to potential subscribers. Experts uniformly agree that repealing ACA in its entirety would have disastrous effects on patients.

Physicians will suffer too. For starters, they will have fewer patients and thus fewer insurance reimbursements. “It’s just like any other business,” explains Joshua Gottlieb, an associate professor at the University of Chicago Harris School of Public Policy. “When you expand insurance, that increases the pool of patients and leads to higher earnings. Losing some of your patients is bad for business.” For many practices that closed due to lockdowns earlier in the year and are still seeing fewer patients than before the pandemic, this will further undermine their financial stability.  

But the overall effects are more nuanced. The ACA had expanded the use of Medicare and Medicaid and established innovative forms of payments to physicians that were based on the patients’ overall health outcomes rather than number of visits and tests. That value-based healthcare aimed not only to reduce costs, but emphasize patients’ health, explains Bob Doherty, Senior Vice President of Governmental Affairs and Public Policy for the American College of Physicians (ACP). “These models encourage physicians to provide high-value care rather than the traditional Medicare and Medicaid model of fee-for-service when you bill for a visit or a procedure,” Doherty says. Some of these programs specifically aim to improve primary care, so if they cease to exist, it would hurt primary care doctors, especially the conscientious ones who adjusted their practice to these models.

Primary care physicians and small practices will likely bear the brunt of this financial hit for several reasons. “Physicians and patients definitely get attached to one another,” says Monya De, an internal medicine and functional medicine physician in Los Angeles. “Some doctors may try to accommodate uninsured patients by charging a much cheaper cash rate than what they bill to insurance companies.”

That will help patients, but strain the providers. “Physicians are put in a difficult position when individuals who come to see them don’t have insurance,” says Kosali Simon, a professor who studies health economics and policy at Indiana University. Many doctors chose to practice medicine to heal and cure people despite their patients’ financial means. “Some doctors have a policy of seeing anyone who comes to their door, whether they can pay or not,” Simon says. “These doctors may face an increased number of patients who can’t pay, but will see them anyway.” This, she adds, can make the physicians’ already stretched finances harder to balance.

Doctors who are employed by larger medical institutions or clinics attached to research centers might be less affected, says Raymond Givens, doctor of internal medicine at Columbia University Medical Center. “For physicians like me who are salaried and paid by universities, it doesn’t really affect my operations, because I have no selectivity which type of insurance I take.”

But Simon notes that some hospitals will suffer too if the ACA is repealed in its entirety. Smaller hospitals and rural clinics might close if a large portion of their constituency loses insurance and stops coming in for care. Even the larger hospitals may see a drop of patients. Meanwhile emergency rooms, particularly at hospitals that accept the uninsured, may see a surge. “Safety-net hospitals and emergency rooms would be hard hit, because patients would not be getting regular care,” De says. The uninsured patients will delay visits so doctors will see them at a worse stage of disease.

Yet, some practitioners might have a contrarian view. “A lot of private physicians actually dislike the ACA, since the contracted insurance rates are so low in terms of what they get paid,” De points out. Healthcare law attorney Benjamin Fenton offers a different opinion. “I don’t think it’s the fault of the Affordable Care Act, I think it’s a bigger issue,” he says. The government-funded insurance pays relatively little, so physicians and doctors spend a lot of time on paperwork, and sometimes have to fight to get paid. “It is difficult being a physician these days,” Fenton acknowledges, but would the reimbursement rates get better if the ACA is repealed? “You’d have less patients in the marketplace and it could make the reimbursement rates go back up,” he says, but it’s not exactly clear.

What is clear for doctors, economists and legal counselors is that revoking health insurance from millions of people during the pandemic is a bad idea. Thus, many experts hope that while SCOTUS may strike some parts of the ACA, the most important ones—those that allow people to stay insured—would remain. This is particularly important for COVID survivors who may suffer chronic health issues and need cardiologists, neurologists, psychologists and other specialists, without whose care they won’t get well, says De. “We don’t need to make this pandemic harder than it already is.”

This article first appeared on medicalbag.com.