Navigating ACA Uncertainty and Affordability From the Front Lines of Care

Summary

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Becker’s Healthcare Podcast

Episode: Navigating ACA Uncertainty and Affordability From the Front Lines of Care

Date: January 15, 2026
Guests:

• Host: Chanel Bunger
• Guest: Dr. Alexander Salerno, Founder and CEO, Nirvana Healthcare Management Services

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Episode Overview

This episode centers on the uncertainty surrounding the Affordable Care Act (ACA), challenges around healthcare affordability, and the on-the-ground realities front-line providers face. Dr. Alexander Salerno shares insights drawn from his experience as a primary care physician and leader of an independent, family-run healthcare organization serving marginalized populations in New Jersey. The discussion delivers a candid assessment of what’s working, what isn’t, and what systemic fixes are needed for both patients and providers.

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Key Discussion Points & Insights

1. Background: Independent Practice and Community Context

• Dr. Salerno introduces Nirvana Healthcare Management Services (NHMS), highlighting its 80-year, family-run legacy and its unique position outside hospital and private equity ownership.
  • Quote:
    “We’re kind of a unicorn because we're family owned, family run. So no strings attached with private equity … So we are a Jurassic dying breed, that is for sure.” – Dr. Salerno [01:17]

2. ACA Tax Credit Extension & Legislative Gridlock

• Discussion of recent congressional efforts to extend ACA tax credits—with the House passing a bill lacking Senate support.
• Dr. Salerno describes real-world impact: growing numbers of uninsured/underinsured patients and looming “sticker shock” for those facing premium increases.
  • Quote:
    “If your premiums start coming in at 100% increase, you’re going to see a lot of people dropping out… it’s going to be a trickle down effect over the next several months.” – Dr. Salerno [02:44]

3. What’s Working, What’s Not with the ACA

• Affordability as a Guiding Principle:
  ACA intended to increase affordability and quality, yet premium and cost escalation have undermined these aims.
• Subsidies as a Band-Aid:
  Subsidies are described as offsetting escalating, rather than affordable, cost levels.
• State-by-State Disparities:
  State opt-in/opt-out decisions yield extreme variations in uninsured rates (e.g., 17% in Texas vs 2% in Massachusetts).
• Systemic Complexity & Unintended Incentives:
  ACA’s complexity allowed large players—private equity, insurers, hospital systems—to exploit regulations (e.g., risk selection, mergers, reduced competition), leading to higher prices and less affordability for patients.
  • Quote:
    “The ACA was kind of like an onion. The more you peeled it, the more you cried.” – Dr. Salerno [04:25]
  • Quote:
    “When you don't have competition, you can't really have competitive pricing.” – Dr. Salerno [05:30]

4. What “Unaffordable” Care Looks Like Day to Day

• Affordability is literal for patients: forced trade-offs between rent, food, medications, and extremely high deductibles.
• Insurance policies resemble catastrophic coverage, leaving many to risk debt or depend on emergency care instead of ongoing primary care.
  • Quote:
    “Do I have health insurance or do I just risk bad debt and use an emergency room when I no longer have access to a primary care doctor's office?” – Dr. Salerno [06:56]

5. Systemic Solutions: A Physician’s Perspective

• On Physician Involvement:
  “Doctors don’t sit at the table… we should be part of the solution and we’re not.” [07:18]
• Proposed Solutions:
  • Cap medical debt.
  • Medicare and PBMs to negotiate drug pricing.
  • Address unaffordable medications, which undermine chronic disease management and value-based care.
    • Quote:
      “When medications are inherently unaffordable, how are we supposed to get patients… to take their meds?” [08:27]
  • Reform elder care—expand and stabilize Social Security and Medicare via increased payroll taxes on top earners.
  • Restore a unified, scientific voice in health policy; suggest National Academy of Science set evidence-based standards.
    • Quote:
      “Medicine is a science, and science should be factual. And I don't know right now if we have truly scientists making clear, consistent standards.” [10:54]

6. Closing Reflections: Advocacy & Professional Voice

• Erosion of the Doctor–Patient Relationship:
  Market forces (private equity, mergers) have diluted this “sacred” relationship, eroding trust and physician identity.
• Call to Action:
  Voters should demand accountability, transparency, and humanity in healthcare policy, echoing the need for better education and more informed, empowered consumers.
  • Quote:
    “More isn’t better, only better is better… It’s time to elect on accountability. And maybe accountability will lead to affordability, transparency and humanity.” – Dr. Salerno [12:04]

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Notable Quotes & Memorable Moments

• On the ACA’s Limitations:
  “Subsidies that have been passed are really, you know, offsetting escalating costs, not offsetting affordable costs… We’re treating a symptom, we’re not treating the disease.” [03:27]
• On State-by-State Disparities:
  “You’re not building a healthy nation when states are opting in or opting out.” [04:06]
• On Standing Up for the Profession:
  “Physicians have lost their voice and they've lost their identity. I think you build a great society on health and education, and we're not there yet.” [11:34]

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Important Timestamps

• 01:03 – Dr. Salerno’s background & practice overview
• 02:04 – Impact of ACA credit uncertainty on patients/providers
• 03:19 – ACA pros/cons: goals vs. reality
• 06:23 – What unaffordability looks like for patients on the ground
• 07:18 – If doctors had a seat at the policy table
• 08:27 – The contradiction of unaffordable medicine in value-based care
• 09:55 – Social Security/Medicare funding solutions
• 10:54 – The necessity for scientific clarity in policy
• 11:06–12:30 – Final thoughts: restoring humanity and accountability in care

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Summary

This episode paints a picture of a healthcare system at a crossroads, with affordability and access challenged by legislative indecision, market consolidation, and rising costs. Dr. Salerno calls for greater physician involvement in policymaking, systemic reforms to address drug pricing and elder care, and a reinvigoration of the doctor–patient relationship. Ultimately, accountability, transparency, and an informed electorate are framed as critical to achieving the ideals promised by healthcare reform—but not yet realized.

Transcript

[A]

This is where healthcare leadership comes together. Becker's 16th annual meeting brings more than 3,500 hospital and health system executives and nearly 800 speakers to Chicago, April 13th through the 16th. This year's event includes keynote conversations with Dallas Cowboys legend Troy Aikman and former President George W. Bush. For the agenda and event details, visit Beckershospitalreview.com and click on the Events tab in the upper right. We're looking forward to hosting you in Chicago.

[B]

Hello and welcome to the Becker's Healthcare Podcast. My name is Chanel Bunger. Today I have the pleasure of speaking with Dr. Alexander Salerno, founder and CEO of Nirvana Healthcare Management Services, who joins the podcast today to Discuss Uncertainty in D.C. when it comes to healthcare policy and the Affordable Care act and how it's affecting providers and their patients. Dr. Salerno, thank you so much for joining me.

[C]

Thanks for having me.

[B]

Perfect. Well, to get us started out, can you please introduce yourself and tell us a bit about nhms?

[C]

My name is Alexander Salerno. I'm an internal medicine doctor, second generation Nirvana Healthcare used to be Salerno Medical Associates. It's evolved. It's been around for about 80 years. We're in three counties in New Jersey and we're in urban areas for the most part and rural area and some suburban areas, areas. We're kind of a unicorn because we're family owned, family run. So no strings attached with private equity and no strings attached with like Hospital Inc. Medicine, as I like to call it. So we are a Jurassic dying breed, that is for sure.

[B]

Thank you so much for the introduction and getting into it. So the House on Thursday passed a bill extending ACA tax credits for three years, but has no path to enactment given that this version has already been rejected by the Senate and as I understand a bipartisan group of senators is working on a compromise deal. What does this mean for you, your patients, and the landscape of care?

[C]

So I'm in urban areas, so we're talking about marginalized populations and you know, we're talking about health care being more of a privilege than what it should be, which is an inalienable right in this country. So this means that we'll be dealing with more underinsured and non insured. And you know, there are lots of numbers out there that are basically, you know, seven digits in the millions range that they're forecasting and predicting can lose their insurance. And you know, I think also a lot of healthier younger folks that initially opted in and bought insurance might, once they get their premiums, get that sticker Shock. So I think, you know, initially, patients might not be signing up as they did in years past, but, but I think even those that did sign up, if your premiums start coming in at 100% increase, you're going to see a lot of people dropping out. And so it's going to be kind of like a trickle down effect over the next several months. So I see this kind of snowballing.

[B]

Absolutely. And as it stands now, what works with the ACA and what doesn't?

[C]

Well, you know, what was the theory of aca? It was about increasing affordability. And that's the key word I think today is affordability of health care while also improving it. And you know, 10 years later, you know, the premiums have doubled, the subsidies that have been passed are really, you know, offsetting escalating costs, not offsetting affordable costs. So, you know, we, we didn't achieve its goal of making healthcare affordable. And, and we're putting a band aid on a problem and you know, we're treating a symptom, we're not treating the disease. You know, what else went wrong with it is it was kind of not a one size fits all approach, even though we're a nation of, you know, 50 plus states. Because, you know, states could opt in and opt out. And if you take for example, initially, you know, Texas opted out, Massachusetts opted in. Well, when you look at the number of uninsured In Texas it's 17% and in Massachusetts it's about 2%, you know, so again, you're not building a healthy nation when states are opting in or opting out. I think the other thing that didn't work is the ACA was kind of like an onion. The more you peeled it, the more you cried. It was really complex when you look at the framework. And that complexity unfortunately resulted in an introduction to certain groups in our society that, you know, kind of prey on complexity to their advantage. And private equity is one of them, insurers are another one, and large hospital systems. So they were able to kind of manipulate the ACA and in turn find a lot of ability for profits and bottom line. And, you know, they started cherry picking patients and, you know, bringing in more of the healthy patients so they could maximize profits by way of risk selection. And with hospitals, you know, they made a, took this opportunity to kind of do a lot of mergers. And in doing that, it kind of changed the landscape. So healthcare wasn't competitive. When you don't have competition, you can't really have, you know, competitive pricing. And so a lot of collateral damage kind of came from ways that people, I guess, manipulated, you know, the complexities of the Affordable Care Act.

[B]

Absolutely. And now we all hear lawmakers and the media talk about affordability all the time. I'm curious to know, in your day to day life as a primary care doctor in New Jersey specifically, since, as you mentioned, it does differ drastically state to state, what does unaffordable care actually look like for the patient sitting across from you?

[C]

It looks at the idea of, okay, can I afford my medications that manage my chronic disease when rent is going up, food expenses are going up, it's can I afford my new 2026 deductible, which makes it look like I have more catastrophic insurance rather than health insurance. I mean, it's a dollar and cents game. Right? So it's yet another added increase in expense in the cost of living that is making people need to make a tough decision. Do I have health insurance or do I just risk bad debt and use an emergency room when I no longer have access to a primary care doctor's office?

[B]

Got it. And with all this said, I'm curious if you could have a seat at the table, how would you like this to be resolved?

[C]

So, as I was saying, you know, unfortunately, doctors don't sit at the table. You know, we should be part of the solution and we're not. And so if I really want to architect a solution, it's a marathon approach, obviously. And you know, it's not a static solution, it's a dynamic solution. But I think one, you know, we should be able to put a cap on medical debt. Number two, I do think, like medicare should be able to negotiate prescription drug pricing and better pricing, and that includes even the pharmacy benefit managers PBMs, which I think you probably have heard recently in the news as they've fallen under scrutiny because drugs are a major cost of health care. And drugs, ironically, you know, we work in what's called value based medicine contracts and certain services are heavily weighted. Medication adherence is a triple weighted measure and it's about medications treating chronic diseases and being more proactive than reactive. But when the medications are inherently unaffordable, how are we supposed to get patients when affordability is such a big issue, to be able to get their meds and take their meds and in turn satisfy triple weighted measures, which are medication adherence. So it's kind of like an oxymoron, if you would. I think we also need to look at like elder care. I mean, you know, the baby boomers are the fast growing generation and, you know, I think the idea of being able to increase accountability and affordability to get old and get old in your home safely is something that really would be part of a new health care measure, protect and expand and stabilize Social Security and Medicare benefits. I think right now, if you look at it, I read that if you take just 10% of the real top earners and only the 10% of the top earners in this country, and you apply a greater Social Security payroll tax on that 10% part of the population, you could probably expand Social Security benefits annually. And you could also extend the funding of Social Security for quite a bit longer than where we find ourselves now. And I think if we can get clear messaging, if anything, unfortunately may be initially coming into Covid, there was a lot of mixed messaging and for good reason. Right. I mean, it was a virus we knew little about and it was pivoting quite frequently. But, you know, I think part of the concern now with the doging of a lot of government agencies, especially like the cdc, we kind of now lost our scientific voice. And so maybe tasking the National Academy of Science to really apply basic evidence and clear messaging and standardized guidelines when it comes to health policy. Medicine is a science, and science should be factual. And I don't know right now if we have truly scientists making clear, consistent standards.

[B]

Absolutely. Well, Dr. Salerno, I want to thank you for your time today, but before I let you go, is there anything else you want to leave listeners with?

[C]

I think listeners should really, you know, when you go into a store, when you go into some retail outlet, you usually know the product, you know what you're getting, and you know who you're getting it from. I think the doctor patient relationship is a sacred relationship that unfortunately has been watered down by, unfortunately, as I said earlier, private equity and monopolizing the marketplace. And in turn, physicians have lost their voice and they've lost their identity. I think you build a great society on health and education, and we're not there yet, you know, and I heard our president say, you know, that we're, you know, the most envious nation on earth. I don't know if that's the case when it comes to health care, certainly. And what we spend on health care, I mean, we spend more on health care than the gross domestic product of Japan. So more isn't better, only better is better and better knowledge and informed consumer that is a voting consumer at the election time. It's time to elect on accountability. And maybe accountability will lead to affordability, transparency and humanity.

[B]

Well, Dr. Salerno. I think that's a great place to end on. I want to thank you once again for your time today, for shedding light on all of these important issues in healthcare, and for joining me on the Beckers Healthcare podcast. Thank you so much.

[C]

Thank you. Take care.