2EMF Understanding Emergency Medicine Providers’ Perceptions of the ACA in a Renewed Era of Health Care Reform: National Survey and Qualitative Mixed-Methods Approach

Abstract

The 2010 ACA has been a source of divisive political conversation and widespread health care reform. In recent months, it has been the center of renewed national attention as many of the law’s key provisions face potential restructuring or repeal. Amidst the changing health system, emergency physicians take on a unique role, serving as the first point of contact for many patients. The objective of this study was to understand their perspectives, illustrating how current and future emergency physicians view the ACA and its impact on patients. The study consisted of 3 parts: a survey of a nationally representative subset of FACEP; a survey of current medical students intending to go into emergency medicine at 8 US medical schools; and a series of 35 qualitative in-depth interviews with current medical students, residents, and emergency physicians across the Yale New Haven Health System. All study parts were completed between September 2017-April 2018. Data were analyzed using descriptive statistics and a grounded theory approach. In order to compare outcomes between surveys, FACEP and medical students were matched on sex, race/ethnicity, and political ideology using coarsened-exact matching. A total of 945 FACEP and 137 medical students interested in EM completed the surveys (response rate: ≥98% FACEP and 36.9% of all medical students surveyed of whom 8.3% were interested in emergency medicine). Overall, 48.5% of physicians indicated having “good knowledge” of the ACA, 59.3% indicated support for the law, and 54.1% indicated that the ACA has resulted in better care for emergency medicine patients. Disagreement with parts of the law (31.9%) and issues with ACA design/implementation (18.8%) were cited as the most common reasons for opposition. Compared to practicing physicians, medical students planning a career in emergency medicine were significantly more likely to self-identify as having “good knowledge” of the ACA (RR[95% CI]: 2.10[1.90-2.31), indicate support for the ACA (1.53[1.39-1.69]), and believe that the ACA has resulted in better overall care for patients (1.35[1.23-1.49]). When asked in interviews about their perceived knowledge of the ACA, EM providers at Yale were more cautious about their proficiency (10/35 reported having “good knowledge”). All acknowledged at least partial support of the law, noting in select comments that “broadening of health care coverage is a moral imperative [⋯] no other viable alternatives have been proposed.” (resident) and that “while I struggle with the law as a whole, everyone deserves health insurance” (physician). All denied changes in their desire to practice medicine and the way that they perceive their work. They did, however, acknowledge an increased number of insured adult patients, awareness of cost-shifting within the hospital system, and concerns among patients with high-deductible private health insurance plans “about the costs of things like observation versus admission.” Both pediatric and adult providers reported seeing more patients. Despite differences in political ideology and concerns about aspects of the ACA, a majority of practicing physicians and medical students report support for the ACA. Future emergency physicians and residents were significantly more likely than board-certified physicians to favorably view the law and its impact on patients, providing insight into the potential direction of health care reform inspired by the next generation of front-line physicians.