New Physicians, the Affordable Care Act, and the Changing Practice of Medicine

Abstract

THE PASSAGE OF THE AFFORDABLE CARE ACT (ACA) in March 2010 signaled a dramatic moment for the US health care system. Featuring expanded health coverage for millions of individuals, insurance reforms, and a commitment to testing numerous approaches to improving the delivery of medical care, the ACA affects nearly every aspect of the practice of medicine. These changes raise the question: how do physicians in general and the next generation of physicians in particular—young physicians, residents, and medical students—view the ACA? Several key features of the law designed to improve the access to and quality of the US health care system could also improve the quality of life and job satisfaction for physicians. First, the ACA will expand insurance coverage to more than 30 million currently uninsured US residents. Furthermore, all US residents with health insurance will have guaranteed coverage of essential health benefits, as opposed to the past of patchwork coverage with numerous exclusions and high rates of underinsurance. Together, these provisions offer physicians the opportunity to improve health care for vulnerable populations, reduce long-standing racial and ethnic disparities in health, and practice medicine without worrying about whether patients will be able to pay for needed care. Beyond its major gains in coverage and access, the ACA also brings a renewed focus on integrated redesigned delivery of health care for the purpose of improving quality. It accomplishes this through supporting delivery system innovations such as the accountable care organization, in which the goal is quality of care instead of sheer volume (as under a fee-for-service model), and the patient-centered medical home, which emphasizes taking care of each patient as a whole person through a system of teamwork and collaboration. Both will support integrated collaborative patient care as opposed to the often fragmented nature of current medical practice. The ACA also creates incentives for primary care, in response to the declining number of physicians in this field relative to the increasing numbers of higher-paid specialists. Beginning in 2011, primary care physicians received a 10% pay increase for their care of Medicare patients. In 2013 and 2014, state Medicaid programs will be required to reimburse primary care physicians at rates equal to those of Medicare. Surveys of practicing physicians present a mixed picture of support for the ACA, but also show that younger physicians are more supportive of the law. One survey of 501 physicians showed that 44% felt that the ACA was “a good start,” 44% described it as “a step in the wrong direction,” and 12% were undecided. Another survey of 2958 physicians showed that 58% thought the ACA would negatively affect patients, and 42% said it would be neutral or positive. The quality of both surveys was suboptimal, with one using a nonrandom sample and the other with a random sample but only a 3% response rate. Setting aside the methodological shortcomings of these surveys, it is easy to imagine why physicians in practice who have presumably adopted approaches that enable them to succeed in the current environment might be ambivalent about the unknown effects of the ACA. For this reason, it may be instructive to focus on the attitudes and behaviors of the physicians of tomorrow—young physicians and medical students. In contrast to the more evenly divided results among all physicians, one of these surveys found that 47% of physicians younger than 40 years (n=140) described the ACA as a good start, while only 36% opposed the law. Students are even more optimistic about the health law. An anonymous survey of 1232 students at 10 US medical schools showed that 68% thought the ACA would expand health care access, whereas 26% were undecided, and 7% said it would not expand access. Overall, 59% supported the ACA, 15% supported repealing the law, and 26% were undecided. In fact, one-third of those supporting repeal of the ACA did so because they felt the law did not go far enough to reform the health care system.