Trade organizations representing physicians and hospitals rushed to endorse the Supreme Court's ruling upholding healthcare reform on Thursday, but there were a few cautionary notes.

The National Association of Public Hospitals and Health Systems, which represents safety net hospitals that care for indigents, expressed concern about states being able to opt out of Medicaid expansion.

-We hope states choose to do the right thing, the NAPH said in a statement. But we cannot base federal policy on hope alone. It went on to urge Congress to reevaluate safety net funding in light of the decision.

Hospitals serving indigents have plenty of reason to worry. Medicaid expansion could add 16 million to 20 million people to Medicaid rolls, meaning hospitals would be paid for their care. But poor people in states that don't expand Medicaid will still be unable to pay hospital bills.

At the same time, the Affordable Care Act calls for $40 billion in cuts to Medicare and Medicaid disproportionate share hospital payments over the next decade. These payments are made to certain hospitals that care for large numbers of low-income patients, with the goal of helping them compensate for the money they lose on indigents. Safety-net institutions are in some cases hanging by a thread. According to the National Association of Urban Hospitals, in 2008 the median operating margin of the country's 448 urban safety-net hospitals was -0.82. NAUH predicts that the percentage of urban safety-net hospitals losing money will rise from a little more than one-half to nearly two-thirds as the result of DSH cuts.

On the physician side, the American Medical Association issued a statement praising the healthcare reform law for expanding coverage and ending insurance company denials for pre-existing conditions, while maintaining our American system with both private and public insurers. But the reaction of 243 physicians surveyed by MDLinx immediately after the ruling was less sanguine. It indicated only 22 percent of PCPs believed the expanded coverage would have an extremely positive impact on their medical practice, and 45.7 percent felt they would suffer an extremely negative impact. Some expressed concern about a shortage of PCPs for all the new patients.

There are an estimated 65 million people in this country living in regions without adequate primary care (Commonwealth Fund). At the same time the number of medical students choosing to go into disciplines such as family practice and pediatrics continues to decline.

The ACA provides some incentives for training new primary-care doctors and increasing Medicare and Medicaid reimbursement, but churning out more PCPs takes time, and even with increases, there is a wide disparity between primary care and specialists income.

All in all, the mixed messages from hospitals and physicians indicate that the promise of coverage for much of the 50 million uninsured is far from reality, and faces pushback from providers worried about the economic realities of our healthcare system.

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