Ask physicians about the ACA this election season and you'll find many don't think they are better off than they were four years ago.
In an election year it's not uncommon to hear candidates talking about the differences between the present time and four years ago. When it comes to the Affordable Care Act and how physicians' view it, four years can make a world of difference. In 2012, 54 percent of physician respondents to Physicians Practice's Great American Physician (GAP) Survey said they supported the health reform law, 29.3 percent said they didn't support it but thought there were a few good things about it, and only 16 percent said they were strongly opposed to it.
Jump ahead to the 2016 GAP Survey and 47 percent of respondents say the ACA has done a great disservice to Americans. Forty-five percent take the middle ground saying, "I think it's mostly good, but not all good," and only 7.5 percent of respondents say, "I think it has been great for Americans." Nearly half of survey respondents (45 percent) say they'd like the next president to repeal and/or replace the ACA upon taking office. The hope of 2012, when the law was in its infancy, has not met up with the reality of 2016 after years of post-implementation challenges.
It's easy to generalize trends from survey responses, but PhysiciansPractice wanted to find out how physicians were experiencing the effects of health reform in their own practices. So we contacted five physicians who took the survey (without knowing their answers to the questions) to get their in-depth thoughts on health reform. Not a single one expressed unconditional support for the ACA. Some were previously fans of the law, but have changed their opinions over time. "A couple of years ago I would have said the ACA was [mostly better for physicians], but as we are proceeding with [major health insurers dropping out], premiums going up, and people unable to afford their deductible, I'm leaning towards maybe this wasn't the right way to do it," says Joseph Zebley, a Baltimore-based family physician at a concierge practice.
Perhaps this frustration comes from four years of having to deal with the negative ramifications of the law. In particular, as Zebley notes, collecting patient deductibles has become more challenging for physicians and their practices due to changes stemming from the ACA. Nearly 40 percent of survey respondents say this was their biggest challenge deriving from the reform law, the top concern. Moreover, 45 percent of physicians say collecting copays and deductibles for patients with exchange plans was their largest collection issue. This, in turn, has led to a changing, more tumultuous patient-doctor dynamic, say physicians interviewed for this article.
New Patient-Doctor Dynamic
For many physicians, this changing dynamic has created an uncomfortable environment when it comes time for patients to pay. This is the case at Stacey Blyth's practice. Blyth, a family physician based in Greensboro, N.C., works for a multispecialty medical group, LaBauer HealthCare.
"The ACA kind of inadvertently consolidated the money and the power in the hands of the insurance companies. I'm at odds all the time with my patients trying to help them get the care they need out of their insurance company. Every time they come in, they want to come in less [after the visit] and do less because they can't afford the deductible, the medicine, any of it. It's horrible. I've practiced 15 years, I did not have this relationship with my patients five years ago," says Blyth.
Brenda Fortunate, a retired family physician who works as a part-time faculty member for Genesys Health System in Grand Blanc, Mich., saw a similar impact on her practice before she hung up the stethoscope last year. "On one hand, we were able to offer preventive exams to almost anyone since that was a provision of the [ACA] and as a family doc, I believe prevention is key. On the other hand, the individuals who have high deductible plans aren't coming to the office because all of a sudden they not only have to pay their healthcare premium, but the full cost of their office-based services as well," she says.
The collection issues have additional ramifications beyond creating a tense environment. At his concierge practice, Zebley says that because patients pay an annual fee, the practice can forgive a lot of the high deductibles by having patients write explanatory letters explaining why they cannot pay the full amount. However, this leads to a slight reduction in overall revenue. With more than 50 percent of responding physicians indicating they can't afford to work less, it appears that he is not the only one with revenue cycle problems.
Arvin Nanda, a family medicine physician at a three-doc practice in Dayton, Ohio, says narrow provider networks are a major repercussion arising from the law that affect his practice since they kick patients off a more cost-effective plan "The insurance costs for patients continue to go up. Many of them can't afford it," he says, noting that like other physicians, he has had some tough conversations with his patients. "Many of the things that are recommended for care are not covered by insurance … even blood work is sometimes not covered."
Major Regulation Overload
One potential mitigating factor in the ACA's decreased approval is the law comes at a time where physicians have been bombarded with multiple forms of government interference, whether it's Obamacare, Meaningful Use, ICD-10, the Physician Quality Reporting System (PQRS), or the impending release of Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Indeed, the biggest frustration with being a physician in 2016, according to the GAP Survey, is third-party interference, which undoubtedly includes federal regulations.
"There is a symbolic nature to the ACA," says Anders Gilberg, senior vice president of government affairs for the Medical Group Management Association. "When you talk to physicians about the ACA … they tend to take a lot of their experiences with the current administration, roll it into one, and associate it with the [health law]. Although there are some discrete different things in the ACA, many physicians don't differentiate the administrative complexity [and] the regulatory burden they've faced. Since the [ACA] was the largest symbol of healthcare legislation in the current administration, when you ask them about it … they roll up a number of their frustrations into it."
Robert Berenson, a physician and institute fellow at the Urban Institute, a Washington D.C.-based think tank, says there are elements of the ACA that both Republicans and Democrats would actually agree are needed, such as alterative payment models, developed under the auspices of the CMS Innovation Center. However, the health law has gotten an overall bad rap by many, he notes, because of the prominent, unpopular provisions such as coverage expansion and the individual mandate. Berenson says many of the ACA provisions actually are widely accepted, even if the law itself may be controversial.
Amend the Law
While there is a somewhat negative tint to how many physicians view the ACA, it's not all bad. After all, nearly half of the respondents to the GAP Survey say it's been mostly good and 7.5 percent say it's been great for the country. Along with the preventive-care factor, Fortunate says the ACA has been great for patients who have benefited from the Medicaid expansion. Nanda says on the positive side, the ACA allows kids under 26 to stay on their parents' insurance plan, which is important for his practice, located near Dayton University. Another positive, he says, is it prevents patients with pre-existing conditions from getting kicked off their insurance plan.
Some physicians say the law can be amended and improved, rather than completely replaced. For Blyth, the answer to an improved ACA is clear. "If we could somehow reinstitute a public option, so that we could show what care really costs vs. what [private insurance companies] are choosing to charge to make record profits, then there could be something here we could salvage," she says.
Nanda doesn't like the idea of a total repeal. "Billions have already been spent on the ACA, to do a total repeal I think puts us back at ground zero and we've wasted all that money," he says. "It doesn't need to be repealed, it needs to be modified greatly."
Repeal the Law
Others, however, are less certain it can be improved and think a total wipe out is necessary. Paul Norwood, an endocrinologist out of Fresno, Calif., is not a fan of the ACA. He says all it did was give the "same lousy system" to more people. As such, he prefers a market-driven system with a lot less regulation, requiring patients to pay out-of-pocket costs for medication, establishing different types of hospitals that are based on the type of care patients are looking for, and transparent prices from physicians.
"The current system is not sustainable and Medicare will not survive," Norwood says. "The danger to the economy is serious, with a $19 trillion debt; it's unaffordable to keep [it] going."
Fortunate has reached the same conclusion as Norwood, but takes a different path to get there. She says if we are going to keep the current system and improve it, "Universal Medicare" would have been the better option."
Zebley isn't calling for a repeal, but he says the way the ACA is structured, it won't work. It has thrown people at the mercy of the insurance companies, and like Blyth, he says the public option should have been kept in. He favors a two-tiered system, where patients buy health insurance for "big-ticket" items and pay out of pocket for less expensive health services.
Whether it's the insurance industry, the Obama administration, Congress, or another entity altogether, many in the physician community feel there is plenty of blame to be passed around when it comes to their frustrations with the ACA. Looking ahead, will the next four years be kinder to the ACA - if it even continues to exist? And will physicians across the country change their view of healthcare reform? A lot depends on the actions of the next administration and Congress.
*Editor's note: Next month, Physicians Practice will explore answers from the GAP Survey on the 2016 election as well as the in-depth thoughts of this panel of physicians on what hopes, if any, they have for healthcare reform in the coming four years under a new president. Stay tuned.
Gabriel Pernais managing editor for Physicians Practice. He can be reached at firstname.lastname@example.org.