Last month’s somewhat surprising Supreme Court ruling to essentially uphold the Affordable Care Act has left us wondering what to expect next. While the emphasis of the ruling rested on whether the ‘individual mandate‘ could be ruled a legal tax – something both sides of Congress disagreed with for different reasons – the overlooked aspect of the ruling is its impact on healthcare for the poor.

Steve Lopez, a columnist for the L.A. Times, recently reported a classic tale of medical care sticker shock. A man brought his daughter to an emergency department, wanting to check to see if she had appendicitis. She didn’t. The bill for answering that question was almost $5,000.

She was rail thin and her deeply wrinkled face reflected the years she had spent sucking on her “cancer sticks”, as she called her cigarettes. I had seen Dorothy many times before in the ED. She had trained so many residents on the nuisances of end stage COPD. The 60/60 rule for intubation, PO2 below 60 or PCO2 above 60 just didn’t apply to her any more.

One of the primary expectations from the passage of the Affordable Care Act was that fewer people would go to the nation’s emergency departments rather than their primary physicians, thereby reducing the overall cost of health care.

After sitting for hours reading the transcript of the Supreme Court oral arguments on the constitutionality of the Affordable Care Act, I had worked up quite an appetite. “It’s about time you came to eat,” my wife said as I came into the dining room. “What have you been doing?” she said without hiding her annoyance. “You know we have the grandkids for the evening.”

“Of course, health care is a right,” my young friend said with a disdainful twist of her face and a shudder that seemed to shake off the unthinkable. “You are a doctor,” she added, reminding me of what I had done for thirty years. “ Surely you agree that health care is a basic human right.”

Have you ever gotten a chance to see how one of your ‘one in a million’ cases turned out? You know, the gunshot to the chest that got opened in the ED and actually lived? In emergency medicine, unless you work in an academic center doing research, most of our cases are lost to any long term follow up. But that doesn’t keep us from wondering just how things turned out.

Senator John Barrasso was “Doctor” Barrasso, an orthopedic surgeon from Casper, Wyoming, long before he came to Washington. So, after the passage of broadsweeping healthcare reform, it came very naturally for him to offer a physician’s perspective on the floor of the Senate. Since then, he’s given these “second opinions” about the unintended consequences of healthcare reform nearly every week.

I don’t often get calls from thoracic surgeons asking for my help. But this was a unique circumstance. His son, a first year student at the U.S. Naval Academy (a plebe as we call them) was going through his first baptism by fire. He was concerned that his son was hitting a breaking point, so he reached out for my help.

It’s a simple question. Given a specific set of facts concerning the presentation of a patient in the ED, what would the reasonably prudent physician do? Or stated more specifically, was an emergency physician’s actions in response to a given set of facts reasonable? This is the “standard of care” against which the physician’s actions will be judged in a case of alleged negligence.