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Photos by Vergil Cabasco

Politics of health

Politics | The known costs plus the unknowns put clinics in jeopardy in the communities Obamacare was supposed to help

Issue: "2010 Election: The Governors," Oct. 23, 2010

SIOUX FALLS, S.D.-Charles Shafer is used to distractions. As the medical director for the Falls Community Health Center, Shafer's day consists of juggling constant demands and questions from patients, nurses, and medical interns at this government-funded clinic in downtown Sioux Falls, S.D.

With flecks of gray in his dark beard, Shafer acts as the clinic sage-patiently enduring interruptions in his own work to parcel out advice to the clinic's 18 medical residents. In one afternoon he helps a young doctor select the right prescription. Then he guides another resident trying to decide if a patient needs a mental evaluation. It's been that way for most of Shafer's two-decade career helping the medically underserved.

With the daily demands of being a frontline doctor, Shafer admits he has had little time to reflect on the looming transformation of his profession under the new healthcare law. "The big picture is going to be-who knows?" he said. It was the only time during my afternoon visit that he didn't have an answer. "I mean, it's a little frightening. . . . I'm fearful that the whole system could come crashing down potentially."

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Six months after President Barack Obama signed the healthcare bill into law, Americans-including the professionals most affected-are still trying to understand what impact it will have on families and businesses. Doctors like Shafer are only certain of one thing: Expect a lot of unintended consequences.

Obamacare for many is a far-off reality, and I found on my cross-country trip that the healthcare debate has taken a back seat to voter angst over the economy. But a recent Rasmussen poll shows that 57 percent of voters now favor repealing the law while 59 percent expect the law will lead to higher healthcare costs. Some Republicans have made healthcare repeal the centerpiece of their campaign rhetoric.

Some Democrats have been touting the reforms that have already kicked in: Dependents can now stay on their parents' policies until the age of 26 while insurers can no longer set lifetime coverage limits. But South Dakota's Rep. Stephanie Herseth Sandlin just wants the healthcare issue to go away. Sandlin, the state's sole House member, has received more than 70 percent of the vote in past elections, and she went against her party to vote against the healthcare overhaul. That hasn't helped her avoid a serious threat this November from Republican challenger Kristi Noem.

Sandlin, 39, comes from political stock: Her grandfather served as South Dakota's governor. Noem, 38, grew up on farms, likes to hunt, and is often compared to Sarah Palin.

Sandlin does not favor repealing the law. But at a debate in Mitchell, Noem said that if repeal fails, she would fight to defund an overhaul she called "too extreme, too expensive."

At Destiny Family Medical Clinic in Sioux Falls, physician Brian Kidman says sorting out the law is "kind of like asking me what I like and don't like about the dictionary."

Before the healthcare law, the Centers for Medicare and Medicaid Services projected an average annual increase of 6.1 percent in national healthcare spending over the next decade; now the Centers predict an annual spending increase of 6.3 percent. The group also found that annual healthcare spending per person will increase by $265 when all the law's provisions are in effect. Another government report, this one by the Congressional Research Service, found that states would face higher costs in light of the law.

Millions of Americans are expected to get their insurance through government-run programs under the new overhaul. Individuals whose income falls between 133 percent and 400 percent of the federal poverty level (currently $10,830 for an individual) will be eligible for subsidized health insurance beginning in 2014. Those making less than 133 percent of the poverty line will receive Medicaid.

In lightly populated states like South Dakota-with a population just over 812,000 and median household income of about $46,000, or slightly more than 400 percent of the poverty level-that means many South Dakotans will likely wind up as patients at places like Shafer's community healthcare center in Sioux Falls.

But already there can be up to a two-month wait to see a doctor here. Since more new doctors are rejecting careers in primary care in favor of lucrative specialties whose higher salaries help pay for medical school debt, Shafer may wind up calling his current workload light compared with what's coming.

"I question if we have the manpower to double the amount of patients we might see," Shafer said. "We already can't get new patients in here. We don't have the slots to do it."

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