On Capitol Hill, the battle over the fate of the Patient Protection and Affordable Care Act (ACA) is in full swing. Amid this contentious and politically charged debate, politicians, special interest organizations, and insurance companies have loudly made their opinions heard. However, one crucial party has remained largely on the sidelines: the U.S. medical community.1
Given the stakes, it is critical that physicians who have concerns about the future of health care in the United States become vocal advocates for their patients. There is growing consensus in the medical community that repeal of the ACA without an immediate and equally effective replacement would be extremely dangerous.2–4 Studies suggest that repealing the ACA without such a replacement would result in over 30 million individuals losing health insurance and destabilize the health insurance market for all Americans.5,6 Because Medicaid expansion has led to a significant reduction in mortality, over 43,000 additional deaths are predicted if the ACA is repealed and not replaced.7 Additionally, this could lead to hundreds of billions of dollars in payment cuts to hospitals, compromising their ability to take care of patients.8 Even if the ACA is replaced rather than repealed, millions stand to lose coverage. The nonpartisan Congressional Budget Office projected that 24 million Americans would lose insurance under the most recently proposed replacement, the American Health Care Act.9 With these potential repercussions, physicians cannot afford to remain silent about the dangers of repealing the ACA. Entrusted with the obligation to protect our patients, we in the medical community have both a professional and moral responsibility to advocate against policies that will actively endanger the health of millions of Americans.
Physicians and other health care workers are uniquely qualified to testify to the human cost of repealing the ACA. Seen through the caregiver’s lens, the effects of ACA repeal become more pressing and less abstract. The 65-year-old uninsured woman presenting to the emergency room with untreated late-stage ovarian cancer, the 25-year-old graduate student requiring expensive monthly immunosuppressive therapy to control her lupus, and the child with cystic fibrosis who grows into an adult with a preexisting condition: these are all stories that attest to how health insurance can be the difference between life and death, or health and suffering.
If we do not share these stories, our voices will be replaced in the debate over the ACA by those who do not understand the fundamental aspects of patient care, and would not confront the real-life medical consequences of taking away health insurance from millions of individuals. More alarmingly, silence from the medical community may suggest tacit approval of ACA repeal, and foster continued misinformation and confusion among patients. A recent poll showed that 45% of Americans were not aware that the ACA would be repealed if Obamacare were repealed, 35% either did not know or were not sure that the ACA and Obamacare were the same thing, and 29% of Republicans surveyed thought subsidies and coverage under Medicaid would not be affected by ACA repeal.10 As physicians remain among the most trusted professionals in the United States, this problem of misinformation is one we can help solve.11 Just as we provide patients clear and factual information about their health, the trusted physician community can do the same regarding policies with clear implications for our patients’ access to care.
Why have so many physicians opted to stay away from the debate over the ACA despite professional organizations’ acceptance of the role of physician as advocate?12 There are likely to be many contributing causes. First, this may stem from a belief that medicine exists outside the realm of politics. Some have argued that combining the two compromises the integrity of the doctor–patient relationship and the physician’s role as an objective source of information.13 Second, the medical education system often does not explicitly prepare trainees for political and social advocacy. Although there is an increasing recognition of the value of advocacy-related training in medical curricula, institutions face challenges in finding time, money, and opportunities to practically address this topic.12,14
For some physicians, this silence is likely driven not only by politics or educational preparation but also by financial interests.15 By moving away from the previous fee-for-service model of physician reimbursement, the ACA may be viewed as a threat to a compensation structure that has been lucrative for many physicians. Basing remuneration on value-based care and preventive medicine introduces an element of uncertainty, which may drive some physicians away from embracing reform.
Finally, even health care providers who do want to speak out on behalf of their patients may fear retaliation from an administration that has made its disdain for the ACA clear.16,17 Hospitals are legally permitted to advocate for or against legislation (without violating tax-exempt status, so long as lobbying does not become a “substantial” part of the hospital’s activities),18 but hospital administrators may be wary of recriminations from a White House administration that has at times rewarded loyalty and threatened those who express dissent.19,20 This lack of communication from executives reverberates down the hierarchy. When hospital directors and department chairs do not set an example of advocacy, they may leave trainees and physicians wondering whether such activism is inappropriate.
There are encouraging signs that the tide is beginning to turn. In recent months, multiple academic bodies, such as the American Medical Association,2 the American Academy of Pediatrics and the American College of Physicians,21 the Association of American Medical Colleges,22 and the American College of Surgeons,23 have expressed concern regarding repeal of the ACA without sufficient replacement. Increasingly, physicians have entered the conversation by writing editorial pieces and, in several notable instances, speaking out on behalf of large institutions.7,24 The CEO of Mount Sinai Health System in New York wrote about the disruptions in care that repeal of the ACA would cause without adequate replacement.25 The medical director of the Massachusetts General Physicians Organization expressed concern that repeal of the ACA and its cost-saving initiatives would undermine Massachusetts General Hospital’s ability to invest in services for its patients.26
Another vocal advocate for the ACA has emerged in recent months: the medical student community. The American Medical Student Association spoke out against the repeal of the ACA, and a grassroots campaign of health professional students coalesced to form the #ProtectOurPatients campaign.27,28 This movement is currently supported by over 5,000 future health care professionals (including the authors of this Commentary) from more than 150 schools and all 50 states. #ProtectOurPatients has delivered a petition to Congress; organized phone banks across the country; met with senators, medical school deans, and hospital administrators; authored editorials in local and national publications; and staged dozens of forums, teach-ins, and rallies to speak out in support of the ACA.28–33 Many of us consider ourselves to be part of the “ACA generation,” and see health as a human right rather than a luxury.
However, for the enthusiasm among students to translate into real change, their actions will need to be taken up by residents, faculty, and administrators. While many students are mobilizing in support of the ACA, they need the guidance and experience of physicians who are ultimately tasked with the responsibility of caring for the patients who will lose their insurance if the ACA is repealed. Students need to see their mentors engaging in purposeful activism: organizing demonstrations and forums, meeting with medical school and hospital administrators, publishing op-eds, attending town halls, and proposing health care policy solutions to Congress. Although some physicians have publicly taken a stance on the ACA, the country needs to hear more from the medical community about what exactly the ACA is, and what is at stake with its repeal. Health professional students need to be taught about social justice and political activism alongside the traditional curriculum. The best evidence-based medicine cannot help patients who cannot afford to see a doctor or pay for their prescribed medications.
The debate over the fate of the ACA will be decided by our legislators in Washington, but it is patients, health care providers, and hospitals who will ultimately bear the weight of its repeal. On this life-or-death issue—and others that affect the well-being of our patients—physicians must not be silent.
1. Kanzaria HK, Brook RH. The silent physician. J Gen Intern Med. 2013;28:1389–1391.
11. Levey NN. Medical professionalism and the future of public trust in physicians. JAMA. 2015;313:1827–1828.
12. Earnest MA, Wong SL, Federico SG. Perspective: Physician advocacy: What is it and how do we do it? Acad Med. 2010;85:63–67.
13. Huddle TS. Perspective: Medical professionalism and medical education should not involve commitments to political advocacy. Acad Med. 2011;86:378–383.
14. Dharamsi S, Ho A, Spadafora SM, Woollard R. The physician as health advocate: Translating the quest for social responsibility into medical education and practice. Acad Med. 2011;86:1108–1113.