The recent election of Donald Trump as President of the United States has created substantial uncertainty about the future of U.S. health policy. The incoming administration has sent mixed signals about the Affordable Care Act (ACA) — embracing some aspects of the law while campaigning against it and pledging to repeal it. The provisions that may be repealed or modified and the new policies that may be enacted are still unknown.
The perspectives of primary care physicians (PCPs) on the potential repeal of the ACA are important for informing the public debate, given PCPs’ central role in the health care system. Patients are most likely to have long-standing relationships with their PCPs and to rely on them to help make health-related decisions that affect their health care costs, quality of care, and outcomes. Moreover, proponents of repealing the ACA, including the nominee for secretary of health and human services, Tom Price, have argued that the law places an undue burden on physicians.1 Although much is known about the general public’s perspective on the ACA, less is known about physicians’ attitudes toward health care reform and its potential repeal.
In a survey conducted between January and March 2015, PCPs were split, with approximately half having a favorable view of the law (48%) and the other half unfavorable (52%).2 A majority reported that they had seen an increase in the number of Medicaid or newly insured patients, without a decrease in their ability to provide high-quality care.
Given that the political and policy landscape changed dramatically over the ensuing months, and that physicians were gaining more experience with the ACA’s provisions, we performed our own survey, by mail, of PCPs from December 2016 through January 2017 to assess their perspectives on the ACA and specific policy options put forth in recent public debate. One thousand physicians, including physicians trained in internal medicine, pediatricians, geriatricians, and family practitioners, were randomly sampled from the American Medical Association (AMA) Masterfile, which contains information on AMA members as well as nonmembers. Physicians received up to two mailings and a telephone call, with an option to complete the survey online. A $2 incentive was provided in the first mailing. Overall, 426 physicians responded to the survey. After we excluded ineligible physicians, our adjusted response rate was 45.1%. Our survey has several limitations: nonresponse may limit the generalizability of the findings, and PCPs may have views that differ from those of other physicians, given differences in political affiliation according to specialty.3
We found that in response to the question, “What would you like to see the federal policy makers do with the Affordable Care Act?,” 15.1% of PCPs indicated that they wanted the ACA to be repealed in its entirety. Responses varied according to the physicians’ self-reported political party affiliation; no Democrats wanted to see the ACA repealed, whereas 32.4% of Republicans did. Among physicians who reported voting for Trump, only 37.9% wanted the ACA repealed in its entirety. PCPs were less likely than the general public to want the law repealed. A Kaiser Family Foundation poll conducted after the election that used a question and response options similar to those in our survey showed that 26% of the general public wants the law repealed in its entirety.4
When asked about aspects of the ACA as it currently exists, the physicians we surveyed almost universally supported the insurance-market regulations that prohibit insurance companies from denying coverage or charging higher prices on the basis of preexisting conditions (95.1% stated that the prohibition was “very important” or “somewhat important” for improving the health of the U.S. population). There was also strong support for other key provisions of the law, including allowing young adults to remain on their parents’ insurance plan until 26 years of age (87.6%), providing tax credits to small businesses (90.8%) and tax subsidies to individuals (75.2%), and expanding Medicaid (72.9%). A lower proportion — just under half — favored the tax penalty for individuals who do not purchase insurance (49.5%).
Among both physicians and the general public, there is a large gap in support between provisions that allow people to obtain insurance without respect to preexisting conditions and mechanisms for ensuring that both healthy and sick people enroll in coverage.4 These results point to an important need to educate health care providers and the public about the fundamental inseparability of these provisions: policies that do not address adverse selection would lead to increased and unsustainable health insurance costs.
Although only 15% of PCPs want the ACA repealed, nearly three quarters (73.8%) favor making changes to the law. Physicians responded most favorably to policy proposals that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts (see graph). Physicians responded most negatively to policies that would shift more costs to consumers through high-deductible health plans. Less than half were in favor of proposals to decrease insurance-market regulations (by allowing insurance companies to sell across state lines), require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.
In the next few months, the country will embark on another major debate about the future of U.S. health policy. According to recent estimates, the health insurance coverage of nearly 30 million people could be at risk if critical elements of the ACA are repealed and the nongroup-insurance market is disrupted.5 As policymakers consider changes to the ACA, they might consider the views of PCPs, given their unique role in the U.S. health care system. We found that PCPs strongly endorse key elements of the ACA that enable individuals to obtain insurance coverage and that very few support repealing the law.
From the Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (C.E.P.); the Department of Medicine, Massachusetts General Hospital, Boston (K.A.); and the Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (D.G.).
1. Roe P, Price T, Fleming J. JAMA Forum: 3 Congressmen’s views on ACA’s flaws, alternatives for health system reform. October 13, 2016 (https://newsatjama.jama.com/2016/10/13/jama-forum-3-congressmens-views-on-acas-flaws-alternatives-for-health-system-reform/).
2. Experiences and attitudes of primary care providers under the first year of ACA coverage expansion: findings from the Kaiser Family Foundation/Commonwealth Fund 2015 National Survey of Primary Care Providers. New York: Commonwealth Fund, June 2015 (http://www.commonwealthfund.org/publications/issue-briefs/2015/jun/primary-care-providers-first-year-aca).
3. Sanger-Katz M. Your surgeon is probably a Republican, your psychiatrist probably a Democrat. New York Times. October 6, 2016 (https://www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html?_r=0).
4. Kaiser Family Foundation. After the election, the public remains sharply divided on future of the Affordable Care Act. December 1, 2016 (http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/).
5. Blumberg LJ, Buettgens M, Holahan J. Implications of partial repeal of the ACA through reconciliation. Washington, DC: Urban Institute, December 2016 (http://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repeal-of-the-aca-through-reconciliation_0.pdf).
This Perspective article originally appeared in The New England Journal of Medicine and then in NEJM Catalyst on February 24, 2017.