In the United States’ long history of trying to reform its messy healthcare system, doctors have sometimes been a stumbling block. Like any group, doctors are reluctant to support legislation that would hurt their pocketbooks.
That tension was on display when the American Medical Association (AMA), the public voice of U.S. doctors, offered its tepid endorsement of the Affordable Care Act (ACA). The AMA supported the bill's bump in Medicaid and Medicare reimbursements, but stayed relatively quiet regarding the expansion of Medicaid to insure the poorest segment of the 30 million Americans the reform promised to cover. The group opposed Medicare expansion outright. The public programs generally pay doctors less for services than private insurers do.
Curiously, a survey later showed that the majority of the AMA’s members supported the Medicare expansion.
Since the ACA went into effect, the debate surrounding it has turned ever more bitterly partisan, but doctors have begun speaking out in support of the law. They’ve expressed frustration with divisive attacks and efforts to defund it.
This week, those voices took center stage with a pair of outspoken op-eds in the front pages of the New England Journal of Medicine. The authors praise the expansion of Medicaid, and shame states that have refused to participate.
Doctor Calls for Civil Disobedience
Dr. Charles van der Horst, the associate chief of infectious disease at the University of North Carolina at Chapel Hill medical school, encourages doctors to engage in civil disobedience to put pressure on the 23 states that have turned away federal funding to expand their Medicaid rolls.
Van der Horst recalls how he was arrested at one of a series of weekly protests intended to pressure Republican state leaders to take federal funds to pay for more Medicaid patients. The federal government is paying 100 percent of those costs for the first three years, at which point it will cover 90 percent of the expenses.
“For a practicing physician and professor of medicine, this was an unusual turn of events in an academic career,” van der Horst wrote. “But given that 23 states have decided not to expand Medicaid, I find it less surprising that I was arrested than that more healthcare professionals have not taken to the streets to protest the harm being wreaked on our patients by decisions driven by partisan politics.”
Doctors have become more supportive of the law as it’s gone from a complicated theory to a reality in which there are more people covered by health insurance.
There are few hard numbers to document how many newly insured patients there are, but 7.5 million people have been added to Medicaid rolls in the states that have expanded coverage since the ACA took effect. Nearly as many bought private insurance through the exchanges the law set up, and the percentage of Americans who lack coverage has fallen.
“The ACA makes financial sense; it makes moral sense. There are so many reasons why this is a better thing,” van der Horst told Healthline. “I think people are increasingly frustrated that the Affordable Care Act hasn’t been fully implemented.”
Partisan politics have pushed doctors to speak out more forcefully, van der Horst said. In the op-ed, he describes partisan politics as a health risk.
“As healthcare providers, we know we have an obligation to protect our patients not only from harmful diseases but from the harmful policies and toxic politics of the current leadership in our state,” he wrote.
What about doctors who, like the AMA, are concerned about ways the reform act might chip away at their incomes?
“There are mixed motives for people going into medicine. Some people want to be rich; some people want to take care of patients,” van der Horst said. “But I think by and large most doctors want patients to have health insurance and access to care. The folks that are against the ACA, they just shout very loudly.”
‘Physicians Haven’t Been Vocal Enough’
Dr. Michael Stillman, an internist at the University of Louisville, makes the case for expanding Medicaid in the remaining states in a dispatch from Kentucky, one of a handful of southern states that has accepted federal funding to expand Medicaid rolls.
“[D]uring the past year, many of my lowest-income patients have, for the first time as adults, been able to seek non-urgent medical attention. I recently evaluated a 54-year-old man … whose last physician visit had been with a pediatrician,” Stillman wrote.
Stillman’s essay also encourages doctors to confront partisan politics head-on.
“I was once uncomfortable discussing politics with my patients, but now I routinely ask them if they are registered to vote and remind them that certain candidates do not support the legislation from which they have so palpably benefitted,” Stillman wrote.
He told Healthline that he thinks doctors have a responsibility to ensure patients understand that the law doesn’t bring government-run healthcare to the United States, as Republicans have claimed. In fact, the law provides structure and support for people to purchase health insurance from private companies.
“I feel like physicians really haven’t been vocal enough about combating the misinformation that’s out there about the Affordable Care Act,” Stillman said. “I think it’s hard to expect your average American to understand that a lot of the information that’s been put out there has been frankly misinformation, or has been tainted information meant to bias them against a law that really can wind up helping most of them.”
Goaded into Activism?
The go-to medical journal has itself been pushed into the fray as the public debate over the ACA continues to smolder.
The editors of the New England Journal of Medicine, led by Dr. Jeffrey Drazen of Harvard Medical School, penned a rare editorial when congressional Republicans forced a partial shutdown of the federal government late last year in an effort to thwart the law.
“As a medical journal, we do not have an official opinion on whether the ACA is a good or bad thing,” they began. But, “as physicians practicing in Massachusetts, where a program similar to the ACA has been in place for a number of years, we strongly support it.”
“Before reform in Massachusetts, we saw too many patients who were devastated by a freak accident or an unexpected diagnosis of cancer; we saved bodies and bankrupted lives. Now, when fate strikes a cruel blow to citizens of Massachusetts, we can fix their bodies and preserve their lives,” the authors added.
The United States Supreme Court recently agreed to hear arguments in the case King v. Burwell, which claims that the federal government cannot give people financial subsidies to help them buy insurance on federally run health websites.
If the ACA can survive a second major Supreme Court challenge, doctors will continue to see the ranks of the insured grow. Some will also see their Medicaid reimbursement rates go up in 2015.
As for the 6 in 10 Americans who still have an unfavorable view of the law, Stillman says, “the longer this law kind of sits with Americans, the more comfortable most will become.”