Doctors in the United States appear as bitterly divided over the Affordable Care Act as the general public.

The Affordable Care Act (ACA), also called Obamacare, has been a lightning rod since it was signed into law in 2010.

Five years after its enactment, the healthcare reform legislation still divides the American public. In a Gallup poll, 50 percent of people surveyed said they disapprove of the act while 44 percent said they approve.

So, perhaps it’s no surprise that America’s 1 million doctors appear to be as split on Obamacare as the general public.

The Physicians Foundation released a survey in which 20,000 doctors responded by email to an array of questions.

Of the respondents, 46 percent gave Obamacare a D or F grade, while 25 percent gave it an A or B grade.

In addition, two-thirds of those responding said they did not accept health insurance plans offered through the Affordable Care Act’s online insurance exchanges.

Those who oppose Obamacare say the survey is an accurate reflection of the country’s medical profession.

Those who support the law are quick to point out the survey was not a scientific poll. They say people who respond to email queries tend to be more critical than the general population.

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The ACA has proven to be a bit of a minefield for medical organizations.

The law has received the backing of a number of medical associations, though some support has been lukewarm.

The American Medical Association (AMA) issued a qualified endorsement of the ACA in 2010. The group said it supported the mandate for insurance coverage as well as the ability to provide greater access to healthcare.

However, the organization voiced its concerns about other aspects of the law.

The qualified endorsement set off a backlash in the medical community. As a result, AMA membership declined 5 percent in the year after the ACA was enacted.

Since then, the AMA has been careful to state its overall support for the law but also list their concerns and desire for improvements.

In a 2012 letter to the Wall Street Journal, AMA President Dr. Jeremy Lazarus wrote:

“While the law is not perfect, the AMA, the nation’s largest physician organization, supported it because it makes necessary improvements to our health care system. We are pleased the law expands coverage to millions of uninsured who live sicker and die younger than those with insurance.”

However, he added:

“The AMA is working during implementation of the law to make changes like eliminating the Independent Payment Advisory Board. Lawmakers also must address two problems that predate the law, the broken Medicare physician payment formula and the flawed medical liability system.”

The primary criticism doctors have of Obamacare centers around money.

For starters, critics say the law has exacerbated the continuing problem of payments to physicians. Dr. Joseph Valenti, a board member of The Physicians Foundation, points out reimbursements to hospitals have risen 35 percent the past 10 years while increasing only 3 percent for doctors.

More importantly, he said, is the provision of Obamacare for people who don’t pay their premiums. It’s estimated that up to 20 percent of people who sign up for ACA plans don’t pay their premiums and lose their coverage after 90 days.

Those patients aren’t required to pay their doctors for any services they received during that time. In addition, insurance companies only reimburse doctors for visits during the first 30 days. After that, the physicians are out of luck.

“It’s a very unfair law,” said Valenti. “It puts the onus on us to determine which patients have paid premiums.”

Valenti said this provision is the main reason two-thirds of doctors don’t accept ACA plans.

“No one wants to work and have somebody take back their paycheck,” he said.

Valenti and others note doctor’s offices are small businesses that are getting squeezed by the low payments, as well as administrative overhead and electronic record keeping requirements under Obamacare.

Dr. Jane Orient, an Arizona physician and executive director of the right-leaning Association of American Physicians and Surgeons (AAPS), said doctors are “under very rigid price controls” with Obamacare.

She said the provision for consumers who don’t pay premiums is particularly grating.

“How many people who don’t work as doctors would agree not to be paid for a month’s worth of work?” said Orient. “Not many people would accept that situation.”

Orient predicts under Obamacare that healthcare quality will decline and consumers will have to pay higher premiums and out-of-pocket costs.

Dr. Richard Amerling, a New York City physician who is president of the AAPS, said Obamacare has set up a “bad business model” for private physicians.

Doctors, he said, can’t adjust their rates to keep up with expenses. In addition, electronic record keeping is a burden both in terms of cost and time.

“A small practice just can’t afford all this,” he said.

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Doctors who support Obamacare acknowledge reimbursements and payments are problems. However, they say those issues were around long before the ACA.

Dr. Robert Wergin, a Nebraska doctor who is president of the American Academy of Family Physicians, said his group supports the ACA for a number of reasons.

He said the law requires health insurance for everybody, encourages preventative care, allows children to stay on their parents’ insurance plans until age 26, and delivers insurance for people with pre-existing conditions.

“Having insurance provides you with access,” said Wergin.

According to the latest Gallup poll, the uninsured rate for U.S. adults has dropped below 12 percent, the lowest rate since Gallup began tracking this statistic in 2008.

Dr. Alice Chen, a Los Angeles physician who is executive director of the left-leaning Doctors for America, agrees.

She tells the story of a patient who had a constant cough. When he finally got insurance, he came in for an evaluation and was diagnosed with congestive heart failure. He’s now getting treatment.

“It’s pretty hard to argue against that,” said Chen.

Chen believes there is a generational divide on electronic record keeping, with younger physicians more open to the requirement. She sees a “net positive” to having electronic records, not the least of which is medical organizations’ ability to share data.

Overall, Chen says the resistance to Obamacare may simply be growing pains as the nation tries to fix its faulty healthcare system.

“Change is hard,” she said. “Being a doctor, taking care of patients is hard. It’s rewarding, but it’s hard. When a big change comes through, there’s a lot to digest.”

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