Kevin Pho, MD, is the well-known KevinMD in the blogosphere, on Twitter and elsewhere. He also practices medicine in Nashua, N.H.

Leading up to Tuesday’s primary in the Granite State, Pho spoke with Government Health IT Editor Tom Sullivan about the healthcare issues important to his state, how politics influence Americans’ perception of health reform, and whether a Republican president could really repeal the Affordable Care Act (ACA).

Q: What aspects of healthcare are unique to New Hampshire? And which issues are paramount to primary voters?
A: Like Iowa, there are a lot of rural settings in new Hampshire. I happen to practice in Nashua, which is less of a rural setting. But a lot of patients come in, their insurance is changing, their premiums are going up, they have more out-of-pocket responsibility for their care and these problems aren’t unique, necessarily, to New Hampshire, but people are feeling a lot of these problems that other patients in the country are feeling. And they’re sharing a bigger load of their care, combine that with the rising unemployment rates people have concerns about the rising cost of healthcare. So these are issues that we a population need to face and a lot of the solutions that I hear during the Republican debates as it pertains to healthcare need to go beyond where they are now. We need ideas, such as replacing the Affordable Care Act with what? I don’t see anything concrete there.

Q: How do you think Americans' perception of health reform is distorted by the politicking in these elections?
A: Health reform in general is very polarizing, especially with politicking. It gets framed in a way that’s black or white, right or wrong, and the issues facing our healthcare systems are significantly more nuanced than that. It goes beyond the soundbites that politicians use to portray health reform.

[Related: In Iowa, candidates afraid to answer healthcare questions. Will N.H. be the same?]

Let’s take an issue like the rising cost of healthcare. The reasons for something like that are pretty complicated. A lot of the solutions involve cutting back on care, thinking twice about the care we give patients and, really, it’s not conducive to a political platform. So I do think that there’s distortion because of the politicking and the campaign promises and I think the public needs to face the harsh reality that we need to make difficult decisions going forward, and that’s not something most politicians want to tackle.

Q: There are certain phrases bandied about that sparked my last question: "socialized medicine," "death panels" and even the term "individual mandate."
A: And you have to remember that the individual mandate was a conservative idea back in the '80s, from a conservative think tank. So to hear the Republican candidates go against it is a little bit ironic. If you look at the conservative concept of individual responsibility, that kind of goes hand-in-hand with the individual mandate. It shouldn’t be as controversial as it is, but I think it is a way for the Republicans to find an excuse to try and repeal the Affordable Care Act.

Q: This early in the elections, healthcare has not been a hot topic because the Republican candidates essentially all want to repeal health reform. If a Republican were to win the White House, could they undo what’s already been done, or somehow stop health reform in its tracks?
A: I would say probably not. If you look at what’s been accomplished in terms of insurers accepting people with pre-existing conditions, and come 2014 they’re going to cover 33 million people without insurance. There have already been a lot of positive effects from the Affordable Care Act, the benefits people already enjoy, and it will be difficult to repeal that. I think everyone’s looking forward to the Supreme Court case to determine whether the individual mandate is constitutional or not. From the analyses I’ve read, even if they do strike it down, I think the core of the Affordable Act will continue. So I think repealing it is going to be extremely difficult from a Republican standpoint.

Q: Health reform is happening on many layers; it’s not just the legislation. But if a Republican president appointed an anti-ACA Department of Health and Human Services Secretary, who is fiscally conservative and wants to stop, for instance, EHR incentive programs, what impact would that have?
A: Various parts of the ACA can be de-funded. Various committees can stop funding to parts of the Affordable Care Act and be rendered ineffectual that way. And if that does happen, it certainly can have the effect similar to an official repeal but it’s an indirect measure. A lot of this is going to be wait-and-see. Many people talk about repeal, but when you get down to the nuts and bolts of it, actually doing so is going to be much more difficult than the rhetoric we hear.