Thomas Hooven, Columbia University Medical Center

As a neonatologist, I worry about patients with pulmonary hypertension. This unforgiving disease, sometimes seen after premature birth, can end with sudden death from constricting blood vessels in the lungs. One minute a baby in the neonatal ICU may be sleeping comfortably; moments later, doctors and nurses are giving chest compressions and rescue medications.

A pulmonary hypertension crisis, as these frightening episodes are called, starts with a drop in the blood oxygen level. That drop triggers a monitor to beep. It’s up to the nurse to hear the sound, come to the bedside and take action.

The first and most effective step in stopping a pulmonary hypertension crisis is simple: Give oxygen. But a nurse caring for another patient might be delayed for 30 seconds, and the loss of that time can lead to brain injury or death.

In an age of self-driving cars and 400-ton airplanes that can land themselves in blinding fog, it makes no sense that hospitalized patients are surrounded by lifesaving machinery that can be activated only by a person pressing a button or turning a knob.

Modern transportation augments human judgment and reaction times with a computer’s superior ability to continuously respond to dozens of fluctuating variables. Yet in medicine, safety remains stubbornly reliant on human intervention.

FDA regulation impedes innovation

My patients with pulmonary hypertension are often attached to a respirator with adjustable oxygen settings. The respirator sits inches below the monitor that indicates how much oxygen is in the blood. But the two machines can’t communicate with each other. If they could, it would be possible to increase the flow of oxygen automatically the moment a crisis is detected.

In 2009, engineers developed just this kind of closed-loop respirator and introduced it in several hospitals as part of a feasibility study. It increased the time premature babies spent at a safe oxygen level by more than two hours per day. But no biotechnology company has marketed the idea.

There are other examples of automated systems with unrealized potential to save lives, and not just in the neonatal ICU. Software that scans an ECG for subtle heartbeat variability can identify patterns – undetectable to the human eye – that indicate an elevated risk of heart attack. Hospital beds that play audible feedback during an emergency promote more effective CPR. Yet patients are not benefiting because neither of these tools has been commercialized.

Why haven’t these innovations attracted the industry backing necessary to make them widely available?

One reason is that the process of getting FDA approval for new devices – particularly those deemed “life-sustaining” – is often even more complicated and expensive than getting approval for drugs. In the Journal of Public Economics, Harvard Business School professor Ariel Dora Stern recently described how FDA hurdles discourage companies from investing in innovation.

Often, the more profitable strategy is to wait for someone else to spend the time and money required to get approval for a new device, and then enter the market later with something similar that will face less scrutiny. Dr. Stern estimates that regulatory obstacles add an average of US$6.7 million to the cost of introducing a new medical device. For a company developing an ICU monitor, for instance, that will ultimately sell for less than $35,000 per unit, this up-front commitment can be prohibitive.

A consequence is that small biotechnology firms (with annual revenue less than $500 million) rarely gamble on getting new inventions approved. Dr. Stern’s paper notes that less than 17 percent of novel device applications to the FDA come from small companies. This is different from new drug applications, the majority of which originate at smaller firms.

What’s behind this discrepancy? Research has shown that while companies pay a steep price for pioneering new medical devices, the first firm to market a new type of drug often gets favorable treatment from the FDA. This raises the incentive for pharmaceutical startups to pursue innovation. In contrast, when it comes to medical devices, the current system discourages all but the biggest players from entering the arena.

And even when a new device has been approved, there is no strong impetus for hospitals and clinics to buy in. Even if they can afford upgrades, medical sites are free to use older equipment, with fewer safety mechanisms, long after improved versions become available.

A chance for Washington to improve health care

In contrast, a variety of government initiatives prod transportation companies to modernize. For example, the Federal Aviation Administration offers rebates to aircraft owners to offset the cost of advanced navigation technology that prevents midair collisions. The Federal Rail Administration is overseeing mandatory, nationwide installation of a GPS-based system to slow down speeding trains automatically.

There is an opportunity here – beyond the messy Obamacare debate – for the White House and congressional Republicans to stimulate economic growth in the biomedical sector while improving patient safety. Streamlining the approval process for new devices and offering financial incentives for early adopters would not threaten anti-regulatory groups, and would allow the new administration to claim progress in health care.

President Trump has expressed interest in expediting pharmaceutical approvals, something FDA commissioner nominee Scott Gottlieb also supports. But most drugs help only a small segment of the population.

The president and Dr. Gottlieb should commit to advancing commonsense technology that makes health care better for all.

I’m not suggesting that machines should take over for health professionals. As in the manufacturing industry, the medical field is experiencing mounting anxiety about job displacement. There are many perceived threats, from artificial intelligence X-ray interpretation to robot nurses.

Those things might become commonplace, but they will never supplant the human relationships and insights at the core of medical practice. Neither will the kinds of safety innovations I’m recommending. With help from our leaders, physicians can take better care of patients by bringing more automation into our wards and offices.

Thomas Hooven, Neonatologist, Columbia University Medical Center

If you live near a hospital, you’ve probably seen the sight: a young physician in loose blue scrubs, standing in line at the grocery store. You can’t help but wonder if the young physician is lost. After all, it appears that he or she belongs in an emergency room – not the dairy section.

The oversized bottoms, dangling bright orange pajama knot, deep V-neck and beeper ensemble not only look out of place, but lead to a slew of thoughts. Is he coming from or going to a shift? Could her clothes carry some sort of hospital microbe? What detritus has the outfit picked up on public transit or in line at the ATM that will track back to an operating room or patient? Has the American trend toward casual attire gone too far?

Regardless of profession, we all play out the sartorial ritual of considering colors, textures, and garments for work, school and play.

Clothing for doctors is more than just a matter of personal style: it is an emblem of their specialty, training and culture.

Making a good first impression

In some cases, a physician’s attire is functional. A surgeon’s scrubs protect regular clothes from stains and patients from infection.

Sometimes, it’s about creating a good first impression and projecting the more professional, conservative image often associated with medicine.

Go to a doctor’s office, for instance, and you’re more likely to find physicians donning a shirt and tie, or jacket and blouse when interacting with their patients. In almost all of these cases, the emblematic uniform of physicians – the white coat – is present.

This month, about 20,000 newly minted physicians will enter residency programs across America, to begin their professional journeys. Each will care for and influence the lives of countless patients.

And each has been trained to avoid “anchoring bias,” or to not to take the first thing they learn about a patient as the most important, lest they reach a biased conclusion or incorrect diagnosis. Yet few doctors or medical students consider the first impression they make on patients. And clothes have a lot to do with that.

In an informal survey in our hospital, only two out of 30 medical students said that they actually thought about their dress when caring for hospitalized patients. Yet, over half of the medical students we spoke to agreed that what they wear is likely to influence patient opinions about their doctors. This illustrates a larger discrepancy between what doctors ought to wear and what they do wear – one that may arise from competing concerns or lack of guidance.

Just like the treatment doctors provide, that guidance should be grounded in evidence. For instance, a special report from infection-prevention experts found little evidence that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far.

Patients really like white coats

We recently published a study reviewing all available evidence regarding patient preferences for physician attire. We examined more than 30 studies that evaluated how patients viewed physicians’ attire.

In 21 of those studies, we found that patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not. Indeed, in 18 of the studies we reviewed, patients had a preference or positive association with this style of attire.

But as we reviewed these studies, three keys themes that suggest important variations in what patients may prefer their doctors to wear emerged. First, studies involving older patients or those from Europe or Asia all reported higher satisfaction when physicians wore formal attire.

Second, in emergency, surgical or intensive care settings, scrubs were not only preferred by patients, but also more often equated with professionalism. This makes sense, as in these more “hands-on,” procedure-oriented settings, formal suits, shirts and ties clearly seem out of place.

Finally, in doctors’ offices and outpatient clinics, scrubs were viewed unfavorably and often resulted in negative impressions.

Thus, from the patient’s perspective, a “one size fits all” approach may not work for doctor attire. Rather, the context in which a patient interacts with their doctor influences what they expect to see.

Given the tension between infection risk and patient preferences, it is not surprising that disagreement about dress code also exists among physicians.

After our study came out, the medical news website MedPage Today reported results from an informal, but still telling, online survey of over 2,000 patients and physicians about the “best approach to dressing for patient encounters.”

About 30% of doctors polled stated that they preferred to wear scrubs, casual attire or had no particular preference when caring for patients. However, more than 60% stated that doctors should wear white coats.

The online comments differed widely, with some physicians defiant in stating that they had “never worn a white coat in 30 years,” while others proclaimed, “priests and judges have their robes, we have our white coats.”

And despite clear patient preferences about what doctors wear while working, even the top-ranked hospitals in the nation, only a handful offer formal guidance on attire. Many vaguely recommend that clothes be “professional,” but without defining what professional means?

A dress code for docs?

How, then, should doctors dress when caring for patients? Clearly, more evidence is needed to guide members of the medical community. So we have launched a large study that aims to better understand what patients prefer when it comes to physician attire.

We plan to survey thousands of patients from the US, Italy, Switzerland and Japan in settings that span outpatient clinics, doctors offices and hospitals. Because generational effects and familiarity matter, we will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions.

While we collect data for this study, what best practices can we recommend in the interim, especially those 20,000 brand new residents?

When in doubt, formal attire with long-sleeved shirts and ties for men, and business attire for women, should prevail in nonemergency or nonoperative settings.

This practice should hold true not just for weekdays, but also when physicians are working weekends and after typical business hours. Patients and their expectations remain unchanged, regardless of hour or day.

While scrubs are appropriate for operating or emergency rooms, we suggest changing into more formal attire to visit patients in the hospital or the clinic. Regardless of the occasion, flip-flops, showy jewelry or jeans simply don’t belong in the hospital, just as scrubs do not belong outside the hospital environment. Especially not in the grocery store.

Vineet Chopra is Assistant Professor of Internal Medicine at University of Michigan.
Sanjay Saint is Professor of Internal Medicine at University of Michigan.

This article was originally published on The Conversation.
Read the original article.

The health and success of the Affordable Care Act (ACA) depends on a lot of factors, and enrolling enough “young invincibles” in health insurance is one of them.

Under the ACA, insurers in the individual market have to cover everyone who wants to enroll. Insurers are also restricted in how much they can vary premiums based on age. That means that older people who have higher medical costs (on average) pay premiums lower than what might cover their care, and young people with lower medical costs (on average) pay premiums sometimes above their expected medical costs. So enrolling young people in health insurance helps keep costs stable. In addition, young adults have historically been highly represented when looking at the uninsured population.

And so millions of young adults were targeted for enrollment in the ACA’s health insurance marketplaces during the first open enrollment period in early 2014.

Enrolling in health insurance can be hard; choosing a health insurance plan that provides the amount of coverage you’ll likely need at the right cost is a difficult task. It’s challenging for consumers who have been through the process several times before, and likely even more so for young people who may be selecting from plan options for the first time.

What young adults want in a health insurance plan

I led a research team at the University of Pennsylvania that examined the experience of young people when they enroll in health insurance on HealthCare.gov, the federal insurance marketplace. At the time of our study, Pennsylvania was one of 34 states that did not have a state-run health insurance exchange. If you don’t have employer-sponsored health insurance, or are too old to remain on a parent’s health insurance, in states like Pennsylvania you have the opportunity to go on HealthCare.gov to choose a plan.

We studied 33 highly educated young adults aged 19-30 in Philadelphia during the first year of HealthCare.gov. Some of the people we followed had health insurance at the beginning of the study, but wanted to look at insurance options on HealthCare.gov because they’d heard from friends that they might get better, cheaper coverage on the marketplace. In fact, one of the findings of our study is that young adults were often not only shopping for coverage on HealthCare.gov, but also comparing those plans to options outside the marketplace, like plans offered by schools, employers or their parents’ health insurance.

From January to March of 2014, we observed the young adults as they shopped for insurance plans on HealthCare.gov, asking them to “think aloud” to capture their reactions in real time. We then interviewed participants about their thoughts on health insurance in general and what they saw on HealthCare.gov.

One said:

I just wasn’t able to comprehend all of the things on the Healthcare.gov – I got confused. I’m not a person to give up, not at all – but with the system, I just wanted to quit.

The young adults we followed were looking for an affordable health insurance option. They placed a lot of emphasis on the monthly premium cost and the amount of plan deductible (though see below on their confusion about what deductible actually means).

Most considered a monthly premium of over US$100 unaffordable, yet the least expensive plan without tax credits in Philadelphia was closer to $200 per month. Luckily several of the participants qualified for tax credits, which brought their premiums as low as $0.13 per month. Others, however, did not qualify for any discounts and chose to remain uninsured, stating that they could not afford any of the options, even though they may have to pay a penalty for not having insurance.

One said:

I will just pay whatever that tax consequence is, $95 or something, right?, because $200 a month right now is way too much. I don’t know how my friends with student loans do it.

Topping the list of coverage benefits they wanted was access to affordable primary and preventative care. One participant said:

I would really like to get a physical to just see where I’m at. I haven’t been to a doctor in a long time, but I wanna see if there’s anything I should be concerned about – blood pressure, cholesterol…

Interestingly, however, many participants in the study did not realize that preventive care was included in all plans at no additional cost under the ACA. Hence, one of the recommendations coming out of this study was that plans should emphasize the availability of no-cost preventive care, like birth control and routine visits, especially in efforts targeting enrollment of young adults.

‘What’s a deductible?’ – young adults aren’t familiar with insurance terms

As one of the young adults was looking at his plan options, he said:

This plan is $20 to see a primary doctor, and this one is 10% coinsurance after deductible – and I just don’t understand that. What is the deductible to see my primary doctor?

It became clear early in the study that one of the biggest challenges the young people faced in choosing a plan was their lack of familiarity with basic health insurance terms like “deductible” or “coinsurance.”

Only half of the participants could correctly define “deductible,” while less than one in five could define “coinsurance.” These concepts are fundamental to understand for anyone who hopes to make an informed health insurance choice. And misunderstanding these terms can lead to a rude awakening after purchasing and trying to use the insurance. This happened to one participant who said:

Before I signed up for it, I didn’t really know what deductible meant. I thought it was saying it would cover $6,000 worth of stuff, and anything over that, then I would have to pay the rest. But I found out it was the other way around.

More support needed for young beneficiaries

While this is a small study that was conducted in a single city and state that uses healthcare.gov, it shows that even the highly educated young people in our study had difficulty making health insurance choices. However, our findings on the confusion over health insurance terms have also been demonstrated in studies of consumers across a variety of demographic groups. Other researchers have also verified, mostly in experimental settings, that people have a hard time making optimal health insurance choices, even after ensuring that they understand basic health insurance concepts or conducting their insurance experiments in a population of MBA students.

Their findings and ours help describe how young adults navigate the insurance selection process, and point to many areas where consumers could be better supported in the health insurance selection process.

In the area of health insurance literacy, tools to help consumers could be as simple as providing pop-up explanations of key terms, like “deductible,” when you hover your cursor over the term on the screen. Other tools might include total cost estimators that do the math for the consumer. This could provide an estimate that takes into account a plan’s deductible, coinsurance, copay and premium amounts, as well as how often that person predicts they’ll use their insurance (such as how many times they visit the doctor and how many medications they take).

We are sharing our findings with those getting HealthCare.gov and the other state-run health insurance marketplaces ready for the next open enrollment period in November 2015.

Charlene Wong is Clinical scholar and pediatrician at University of Pennsylvania.

This article was originally published on The Conversation.
Read the original article.

Despite the government’s push to make health information more available, few people use concrete information about doctors or hospitals to obtain better care at lower prices, according to a poll released Tuesday.

Prices for the health care industry have historically been concealed and convoluted, unlike those for most other businesses. The 2010 health law aimed to make such information more transparent. People shopping for insurance can now compare the prices of competing plans through online marketplaces, including premiums, deductibles and their share of any medical expenses. The federal government also publishes more than 100 quality ratings about hospitals, as do some large private insurers. Private groups such as Consumer Reports and U.S. News & World Report also rate providers, and Internet forums such as Yelp are now littered with easily accessible opinions.

The poll from the Kaiser Family Foundation found that about two of three people say it is still difficult to know how much specific doctors or hospitals charge for medical treatments or procedures. (KHN is an independent program of the foundation.) Only about one in five people said they had seen specific cost or quality information about a hospital, insurer or doctor.

The poll found that this information rarely makes a difference. About 6 percent of people ever used quality information in making a decision regarding an insurer, hospital or doctor. And fewer than 9 percent used information about prices, most commonly in relation to health plans. Only 3 percent said they used price information about physicians, the poll found.

This lack of practical information may be related to another major finding from the poll: people are overconfident about their ability to pay medical bills without financial strain.

A majority of people told pollsters they had enough insurance coverage or money to pay for their usual medical costs or for an unplanned hospitalization. A majority also said paying insurance premiums, deductibles and their share of medical costs was relatively easy.

However, when asked how they would handle an unanticipated $500 medical bill, only 47 percent of insured adults under 65 said they would pay the bill in full immediately. The others said they would put it on a credit card and pay it out over time, borrow money or not be able to pay the bill at all. Not surprisingly, those bills would be a bigger problem for those who lacked insurance.

If the medical bill were $1,500—a sum that is less than the deductible in many insurance plans— 25 percent of people with insurance thought they could pay it off immediately. Another 29 percent said they would add it to their credit card debt, and 25 percent said they could not pay it at all.

The poll was conducted April 8 through 14 among 1,506 adults. It has a +/- 3 percentage point margin of error.

This week I answered questions from people about health insurance cost and coverage rules, including how getting married or working here as a foreign national may affect them.

Q. Last year, I had single coverage through the marketplace from January through May. Then I got married and canceled my policy because I had coverage through my husband’s job for the rest of the year. When I filed my 2014 taxes, we had to repay half of the premium tax credits for the months when I had a marketplace plan. Why? Those first five months I was single and relying on my own income. Why should my husband’s income be counted?

A. The Internal Revenue Service has a special rule to handle situations like yours when people get married during the tax year. Though not a perfect solution, without it, chances are you would have had to repay even more of your tax credit.

First, some background: The premium tax credits that people can qualify for if their income is under 400 percent of the federal poverty level (about $46,000 for one person) make coverage purchased on the health insurance marketplace more affordable. Like you, many people opt to receive the credit in advance and have it sent directly to their insurer, which reduces their monthly bill.

The amount of the tax credit is based on your annual household income, which you estimated when you signed up for coverage. At tax time, your estimated income is reconciled against your actual income and, if the estimate was too low, you have you repay the excess, up to a cap.

That’s the situation you found yourself in. However, when people marry during the tax year, the IRS offers an alternative way of calculating household income that for many reduces the excess premium tax credit they have to repay.

Under the IRS rule, the tax credit for the months when you were single is computed as if your annual household income were half of what it actually was. So if your joint income was $70,000 for the year, your tax credit will be computed on a $35,000 income rather than the whole $70,000.

Using that alternative calculation will generally reduce how much people have to repay.

Though not a precise income adjustment, “this creates at least some rough justice, in giving people a chance to simulate what they made when they were single,” says Judith Solomon, vice president at the Center on Budget and Policy Priorities.

IRS publication 974 has step-by-step instructions on how to do the alternative calculation, and tax preparation software generally incorporates that option.

Q. I am on a H1B visa, legally working in the United States. My employer provided my husband and me with health insurance, but it is costing us a lot. My husband is here on an H4 visa as my spouse. My question: Is it mandatory to have health insurance for him? What are my options?

A. In general, people who are living in the United States legally are subject to the health law requirement that they have health insurance. There are some exceptions for foreign nationals who are here only briefly, but as someone who is living and working here and has employer-sponsored health insurance you likely pass the IRS test for having a “substantial presence” in the U.S., says Sonal Ambegaokar, a senior attorney at the National Health Law Program, an advocacy group for low-income and underserved people.

To avoid the penalty for not having health insurance, you and your husband must have coverage unless you qualify for an exemption. Since you say that coverage is expensive, one possibility might be an exemption based on affordability, says Matthew Lopas, a health policy fellow at the National Immigration Law Center.

If the cost of your plan is more than 8 percent of your income you’d be exempt from the requirement to have coverage.

Q. If a person does not pay the premium and is charged a penalty for not having health insurance, is that penalty considered to be a partial payment of the premium and does it provide any health benefits?

A. No on both counts. The penalty for not having health insurance, which you pay when you file your federal income taxes, is completely separate from the health insurance premium you would pay to an insurer to provide coverage. The penalty can’t be applied to insurance in any way and provides no health benefits.

For 2014, the penalty is $95 or 1 percent of your income, whichever is greater. If you’re uninsured and didn’t realize you would owe a penalty for last year, you may still be able to sign up for 2015 coverage, says Cheryl Fish-Parcham, private insurance program director at Families USA, an advocacy organization. You’d still owe the fine for 2014 but you could avoid it for this year, and you’d have insurance that could provide benefits that the penalty cannot.

If this scenario fits you, better get cracking. The special enrollment period ends April 30.

The Affordable Care Act mandates that all Americans get health coverage or pay a penalty. To help people pay for that insurance, the federal government subsidizes insurance premiums for millions of Americans.

In just a couple of months, the Supreme Court will rule in a major case concerning those subsidies. The question is whether the law allowed for them across the country or just in the minority of states that set up their own insurance exchanges. A decision to take away those subsidies could leave millions without insurance.

Attorney Tom Goldstein, who runs SCOTUSblog, has been following the case and says the law is ambiguous. “This is a real, serious question,” he says. “The law doesn’t tell you whether Congress wanted to limit the subsidies only to those states where the state itself went to the trouble of setting up the exchange or whether Congress wanted everybody who needed the help to be able to get the subsidies.”

Louisiana is a state where a lot of people could be affected. It runs healthcare.gov and about 186,000 people there have used the site to buy health insurance. Nearly 90 percent of them in Louisiana get subsidies.

We traveled to the state to interview many of these people who could lose subsidies if the Supreme Court rules against them. Here are our first three profiles:

Carlton Scott
Carlton Scott is 63. Sitting at his kitchen table at the house he owns in Prairieville, near Baton Rouge, he says he worked at a chemical plant for 30 years before he retired. He found out last fall that his company was scaling back his retiree benefits.

“’Round October they wrote me a letter saying, in December we’ll no longer be covered,” he says.

That included his health insurance, which he was really counting on.

“I thought they would take me to my grave. I really thought the company would take me to my grave,” he says. When it went away, “That pissed me off. Because, god——, I been through 30 years and you come with this bullsh–? That pissed me off.”

And he was in a bind. At 63 he is too young for Medicare and Louisiana hasn’t expanded Medicaid. Obamacare was a good option for him.

He signed up for a BlueCross BlueShield of Louisiana plan. He says he pays $266.99 per month, “to the penny.” Like a lot of people, he could rattle off the exact amount. Money is tight and people track their expenses carefully.

Scott could be in a position to lose his subsidy and his health insurance. He says if he had to pay more, he could for a while. He gets $2,600 a month between Social Security and his pension. But he worries about his friends.

“Everybody don’t make the same amount of money, that’s what I’m saying. I got a friend of mine, stay down the street. He gets Social Security and pension, too. But it’s not as much as mine, not half as [much].”

When asked about the case in front of the Supreme Court, he laughs.

“They all got insurance, too. I guarantee you that. They all got insurance.”

He says the court should, “Leave it like it is. I mean, what are people going to do? Get sick, go to the hospital, ‘I don’t have insurance. Won’t you please help me anyway?’ Hell, no. That ain’t going to happen,” he says.

LaTasha Perry
LaTasha Perry is at the other end of her career. She’s 31 and works at the front desk of a community health center in Plaquemine, La. She got covered under Obamacare because it was cheaper than paying the penalty.

She says her children have Medicaid as their health coverage. Her job offers health insurance, but she says she can’t afford to buy it.

“I would pay at least $100 a month for the insurance here,” she says. “With my subsidy, I pay $13.”

Now she’s got money left over for necessities: “Food for my kids. I’m a single parent, so it’s hard.”
Charles Dalton
Charles Dalton wanted health coverage. He’s 64 and after he retired as a paramedic, he didn’t have health insurance. Then he got sick. He says his condition is too personal to talk about. “I’m disabled,” he says. “But I would be totally incapacitated without seeing this doctor.”

The Affordable Care Act says insurers can’t take into account whether somebody is sick, like they used to. That made insurance unavailable or unaffordable for many sick people. And now — with subsidies — Dalton says he pays $149 a month. He hopes the Supreme Court doesn’t touch the subsidies.

“They’re just going to make a difficult situation more difficult,” he explains. “Because of the Affordable Care Act, it’s helping me to be able to make this existence more livable. You’re not asking for a handout. But if you get a helping hand, the last thing you need is for it to be snatched out from under you.”

Regardless of the politics, there are a lot of people like Dalton who could feel that the Supreme Court would be taking something away. Goldstein of SCOTUSblog says the court has a tough job.

“This is a case that requires the justices to be both lawyers and try and look at the words that Congress used, but also to struggle with the human dimension of the case,” he says. “The consequences are so real and so powerful that, if the challengers win here — and maybe they deserve to win, maybe it’s what Congress intended — but it’s hard to avoid the conclusion that millions of people would lose access to health insurance.”