Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on the present and future impacts of current health care reform efforts on medical education, health care delivery, and research at academic health centers, and the effects such reforms might have on the overall health of communities.
Citizens’ participation in the voting process is one of the basic tenets of democracy. Every two years we have elections in the United States, and citizens, our patients, have the right and opportunity to vote. Billions of dollars are spent on campaigns through television, cable, and other media. Our patients receive ample amounts of information that can inform their voting decisions.
But how do we measure the accuracy of this information? Even with all of this information at their disposal, are our patients able to make an informed decision? What is our role as their physician? When we care for our patients’ diabetes or heart disease we inform and educate them about their diseases. Despite the fact that many elections involve issues central to the provision of health care, many of us hesitate to similarly inform our patients about election issues related to health care.
During my sabbatical, from April through July 2016, I rode my bike from Washington, DC, to Seattle, Washington, passing through small towns along the way. In each of these towns I interviewed people I randomly met in cafes to learn their understandings of the Affordable Care Act (ACA). My intent was to listen, and I did not correct any inaccurate comments made during these conversations.
Many themes emerged both opposing and supporting the ACA, which some referred to as “Obamacare.” Opinions opposing the ACA included the following: It’s too complicated; it’s wrong to obligate people to buy insurance and penalize them for not buying it; it’s too expensive; premiums have increased since the ACA; deductibles are too high; it rewards people who don’t want to work; the insurance industry is for profit and shouldn’t be involved with health care delivery; and networks are too narrow and people can’t keep their doctors. In support of the ACA, I heard the following: Children up to age 26 can remain insured and make career/job changes without fear of uninsurance; there exist no added costs for preventive care services; the financial insecurity index has decreased, particularly in states with Medicaid expansion; and Medicaid expansion has led to significant decreases in uninsured people.
Before I set out on this project, I submitted the protocol for ethical review and received an exemption from the University of Arizona human subjects protection program. What follows are a few people’s stories illustrating certain key themes. In every case, I have changed the person’s name and have avoided providing specific details about locations in order to preserve the anonymity of the people who spoke with me.
Stories and Themes
It’s too complicated
Samir is the manager of a motel in eastern Maryland. He has always been insured through his work and tells me, “I just don’t understand economics.” Samir believes that to understand the health care system you need to understand economics.
As the motel manager, he listens to his guests. They seem really upset about “Obamacare” and simply don’t want to have anything to do it. They don’t want to pay for it. He thinks his guests are opposed to anything from the Democratic party. Personally, Samir hasn’t seen a doctor since 1999. He has neck and back pain, but waits for it to heal.
He then tells me about his aunt who needed a knee replacement. Although she works with him and has insurance, she doesn’t understand it. Since she doesn’t speak English very well, she went to India for the surgery.
The deductibles are too expensive
George and Sally are a father and daughter I met in an Allegheny County, Maryland, cafe. George has his insurance through his retirement benefits; Sally is insured through her spouse, who is a state employee. They have no personal problems with insurance, but they spoke of their customers who tell them frequently about how hard it is to pay for insurance. “Those damn deductibles are too much,” they said.
I also spoke with Pat, the owner of a market, in Fayette County, Pennsylvania. She summed up “Obamacare” by saying: “Pay, pay, pay. It’s too confusing to navigate, the deductibles are too high, and there are too many parts.” Since the ACA began, her premium has doubled, and the deductibles keep going up. When she tried to choose a plan, it was confusing with all of the different premium and deductible options. She now relates, “I just won’t go to the doctor, even though I’m insured.”
President Obama said we could keep our doctor
Shirley, the owner of a family restaurant in Allegheny County, Maryland, was clearly upset about the ACA. She said, “people don’t like being told what doctor to go to,” and that President Obama had said “we could stay with our doctor.” Since “Obamacare,” however, people in her area were no longer able to continue with their personal doctors because the doctors would no longer accept the new insurance.
Those where Medicaid expanded are better off
Miriam and Eric, two self-identified progressives, live in the metro Washington, DC area. They believe the most positive impact of the ACA is how children, up to the age of 26, can remain insured on a parent’s health insurance policy. One of their children remained insured throughout graduate school. The other child, at the age of 25, was able to make a significant career change without the fear of being uninsured. She is now able to work as an independent contractor without the expense of health insurance.
Miriam works with low-income populations, where one of the outcome measures that her organization tracks is household financial security index. She has seen enormous changes in this index since the implementation of the ACA, and notes this change was demonstrably different between those states that expanded Medicaid coverage and those that did not. The number of uninsured citizens has decreased substantially more in those states that adopted Medicaid expansion.
Health care is a right, but …
“Obama made a pact with the devil.” These words came from Joan, a self-identified progressive who owns her own business. In all the developed countries in the world, she states, everyone has health insurance: Health care is a right. This is good not only from an ethical perspective but also from an economic one, because countries function better when people don’t have to worry about health care costs. Here in the United States, the ACA is a first attempt at ensuring universal health care, but it doesn’t accomplish all three goals of a health care system: accessibility at reasonable cost and reasonable quality. The cost has been too high, mainly because of increasing co-pays and deductibles, shifting costs to the patient. The attempt to improve quality used unproven ideas like accountable care organizations. This has caused stress and burnout in the health care workforce with no significant benefit. She acknowledges all of the compromises President Obama had to make politically to get the ACA through Congress, but believes we can do better.
Joan believes maintaining the private insurance industry was a mistake. As for-profit entities, insurance companies’ first priority is to deliver dividends to their shareholders; delivering health care is secondary. That’s where the “pact with the devil” comment comes in: President Obama allowed the insurance industry to control the way insurance was sold through the exchanges.
Joan supports a national health insurance system. Of all the systems in developed countries, she believes the Canadian system is the best. Its payment system is government funded, but the delivery system (doctors, hospitals, etc.) is private. Patients maintain their choice of doctors. The money saved on administrative costs (which account for roughly 30% of health care expenditures in the United States)1 would cover all uninsured people in the country. Such a system in the United States could be based on a progressive tax, which Joan thinks is more equitable than our current system and believes is appropriate.
Joan does not think there is a way to “improve” the ACA.
Too many regulations
I had a couple of conversations in a cafe in rural western Pennsylvania. One was with two local people having lunch and the other with the owner of the cafe. Derek and his buddy are employed in a company of about 200 people. They feel their boss is good and always working to get the best deal for them. But, since “Obamacare” started, things have been bad. Their insurance company changed and then, after the first year of coverage, their portion of the premium has doubled. They feel “it’s all the regulations. When you have politicians trying to make health policy, it’s never going to work. Too many politicians and too much regulation—2,000 pages of regulation.” (The ACA legislation clocked in at around 2,000 pages.) Derek’s buddy is afraid to go to the doctor since it would cost too much. He won’t even get the preventive visit that’s provided in the insurance since he knows it would be too expensive to do any of the follow-up visits or treat any of the problems the doctor would potentially identify.
The owner of the restaurant had been previously insured as an employee. She retired from that position when “Obamacare” began and now has to insure herself through the marketplace. Although she understands that part of her premium is to pay for others’ problems, she objects to paying for those other people. We talked about the parallel to car insurance, which she understands very well, but she similarly objects to her car insurance premiums that might offset the costs for others who are not safe drivers or for motorcycle riders who don’t wear helmets.
On the other hand, “You can choose whether or not to drive a car, but you can’t choose whether or not to be alive and need health insurance.” I also had a conversation with Rob, a 35-year-old musician in eastern Ohio. He had not been insured before the ACA, but with the start of the ACA he purchased insurance privately, not through the marketplace. He was very knowledgeable about the ACA, telling me many of the benefits related to preexisting illnesses, etc. He also understood very well the reasons for the individual mandate. Although it was expensive for him as an individual, he found the mandate to be an appropriate component and had purchased his insurance privately though he was aware of the marketplace. He knew about subsidies but didn’t think he qualified for them. He also articulated some of the problems with our prior health policies, referencing a former significant other with Crohn disease who was unable to qualify for insurance before the ACA but who, he imagines, now is able to get insurance. Nonetheless, he was not a fan of the individual mandate because he felt he was being forced to get insurance. When we talked about the similar mandate related to car insurance, he said that driving a car was a privilege chosen by certain people, so he did not think these mandates were the same. Rob believes that the threefold increase in the premium for his privately purchased insurance is due solely to the individual mandate. He states that, “since insurance companies can, they are extracting more revenue from the population.”
The American Medical Association (AMA) Principles of Medical Ethics lists as its third principle, “A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.”2 How do we interpret this principle from the AMA, and how do we demonstrate it in our daily work with patients?
There is no doubt that our health care system is complicated. Health care cannot be explained in 10-second sound bites. The stories in this Commentary reflect legitimate concerns from our patients, but are often based on misinformation. Yet, as the word “doctor” comes from docere, the Latin word meaning “to teach,” I believe our responsibility as physicians is not only to teach our patients about their diseases but also to educate them about the system through which they receive care for these diseases.
I acknowledge this is a tall order. So is being a physician.
An important component of the ACA (or any universal health care system) is community rating, which necessitates that health insurance providers offer policies within a given territory at the same price to all persons without medical underwriting regardless of their health status. When everyone is insured through community rating, premiums can be kept down. Another challenging theme is insurance as a safety net. We pay into it because we never know whether we will have medical conditions that are costly to an individual if not shared broadly.
Another concern expressed related to how complicated the system is. I agree. An unexpressed component of “It’s too complicated” relates to each individual’s risk tolerance. Choosing a premium/deductible combination is placing a bet on the next year of your life. To help patients navigate this decision, we might ask our patients whether they think they are likely to suffer an illness in the next year. Risk tolerance is an individual issue, but we can help our patients understand it and make more informed decisions.
Finally, the economics are difficult. Insurance means we make short-term payments under uncertainty of future outcomes. This is a key point that needs to be distilled into simple language. We pay small amounts now to avoid potentially very costly payments in the future.
I believe my role as a doctor can include helping my patients navigate the system through a better understanding of it and of their own requirements, and helping them get what they need in an imperfect world. I have a role and responsibility in society as a knowledgeable person to make the health care system be the best it can be for the most people. I do this as an advocate for my patients.
The themes I discussed above will suggest to readers that I am encouraging physicians to talk with their patients about health care policies. They are right. These are all very complicated issues I believe we can help our patients understand.
Some might object that it is not our role as our patients’ doctors to get involved with these issues, as they may touch on politics. Yet there is a difference between politics and what I am advocating our role to be. I am not suggesting that we campaign for a given candidate, nor suggest to our patients how to vote. I believe the inherent hierarchy in the doctor–patient relationship makes any discussion and suggestion to our patients about how to vote an inappropriate use of our role. However, as doctors, we are teachers. It has been overwhelmingly clear to me throughout my travels that our patients are basing their opinions about health care policy—an extremely complex issue—on their emotional responses to sound bites aimed at triggering purely emotional responses.
As an academic physician teaching students and residents, I believe it is our responsibility to educate our patients about the complexities of health care to enable and empower them to make informed decisions. Understanding the perspectives of an extremely varied group of people I met on my bicycling adventure has informed my thinking. The conversations I have had while riding my bicycle across the country have provided me with a richer understanding of people, and I hope that sharing this understanding with my learners and patients makes me a better teacher.
Understanding what our patients think, particularly at this time during an election whose outcome will influence the health care policy that will affect us and our patients, allows us to recognize our responsibility to educate our patients to help them make informed decisions. Some will call it politics; I consider it our duty as physicians.