As you envision your future medical career during this application season, thoughts of caring for your future patients most likely sit— and rightly so—at the forefront of your mind. However, in addition to caring for individuals, physicians also play a pivotal role in nurturing the health of their communities and the population as a whole.
Indeed physicians hold an important leadership role in shaping the system by which we deliver healthcare. This is a fact which medical schools astutely recognize. In these recent years of hotly-debated reform, questions on healthcare policy have taken on a more prominent role in the medical school interview.
At the center of healthcare reform in the United States for about the past decade has been the 2010 Patient Protection and Affordable Care Act, frequently abbreviated ACA or simply called Obamacare. This roughly 2,300 page treatise enacted numerous changes to the healthcare system in the US and has inspired thousands of additional pages of policy and rhetoric along the way.
So as an aspiring physician with medical school on the horizon, what do you need to know about all this to ace your interviews? In this post we’ll cover the motivation for the Act, its most prominent tenets, and a bit about what is keeping it a hot topic today.
What Made Obama Care? Motivations for the ACA
Healthcare delivery in the United States differs from that in many other industrialized nations. Many countries offer centralized and government-sponsored health coverage to all citizens (universal healthcare), such as the United Kingdom’s National Health Service. In some cases the government also foots the entire bill for these services via taxation, which is known as single-payer healthcare.
By contrast, in the United States there exists a combination of public health insurance through Medicare and Medicaid, many private health insurance providers, and the option to forgo medical insurance. The costs are shared between individuals, employers, insurance companies, providers, and the various levels of government.
This complex system is able to offer truly excellent care to many. It provides the most advanced care available for many diseases, supports ground-breaking research, and often offers patients with some degree of flexibility in where they would like to be seen. However, healthcare delivery in the United States has also long faced a number of well-publicized problems which the ACA attempts to address. Here are the key issues facing American healthcare today:
1 | Healthcare is Expensive!
Whether measured per capita, as percentage GDP, or in total expenditures, the US ranks in the top several nations in money spent on health care. Moreover, expenses had been growing at near exponential rates in the decades leading up to the ACA, constituting a strain on the Federal Budget and the economy at large. Governments, health networks, and patients all shoulder the burden of this expense.
2 | Many People are Left without Health Insurance Coverage.
With rising prices for healthcare services, the prospect of paying large sums out-of-pocket serves as a deterrent to those who would otherwise purchase healthcare coverage. This becomes especially troubling when individuals cannot access basic health resources, to manage chronic diseases or screening for cancer for example, leading to dire health consequences over time.
3 | Suboptimal Outcomes
All these factors lead to suboptimal outcomes in many key health areas compared to our peer nations. Despite investing the most, the United States has not been reaping the expected benefits.
Pillars of the Affordable Care Act
It was in this environment that the Obama Administration spearheaded a major healthcare reform effort, and with eventual Congressional support the ACA passed into law in March 2010. As alluded to earlier, it is a lengthy and broadly-reaching law, but some of its most consequential points are as follows:
1 | Patient Rights
The law provided numerous protections for consumers/patients including a ban on annual and lifetime limits on insurance coverage as well as the ability of insurance companies to deny coverage based on preexisting conditions. You have probably also noticed that young adults are able to remain on their family’s insurance policy through age 26. These are all parts of the ACA.
2 | Expansion of Medicaid
This was hugely influential portion of the Act. At Federal expense, the expansion made anyone within 133% of the poverty line eligible for Medicaid at no personal cost. This effectively extended coverage to millions. Of note, states can decide whether or not to accept the coverage expansion, and many opted not to.
3 | Health Insurance Marketplaces
A core goal of the Act is to extend more affordable coverage to all, and to facilitate this an online marketplace was established so that individuals could directly compare and purchase health insurance plans. For those between 133%-400% of the poverty line some subsidies are available as well. This went live in 2014.
4 | The Mandate
The insurance mandate set a tax penalty for those choosing to forgo medical insurance. As the first ever policy applied towards medical insurance, it has been the center of much of the controversy surrounding the law. There is an exemption process for those who cannot afford coverage.
5 | Quality over Quantity
Another strong theme of the ACA, and in healthcare broadly these days, has been to improve efficiency and promote high value care. As such, preventive services were required by the ACA to be without out of pocket cost, electronic health record systems were promoted, and Medicare saw payments restructured to emphasize quality metrics rather than simple fee-for-service. This latter point is a complex and evolving theme throughout medicine.
Where are We Now?
The years since the full implementation of the ACA have brought both successes and challenges. Among its biggest achievements, the ACA’s patient rights provisions immediately improved inequities within the system. The theme of high value care has also taken a strong hold within academic medicine, and while health expenditures continue to rise, the growth rate is generally less staggering than in the years leading up to the ACA. Perhaps most importantly, millions more Americans now have health insurance since the Act (see figure below), improving access to healthcare overall.
These changes are of course far from perfect and far from universal. Out-of-pocket costs and other barriers continue to limit appropriate access to healthcare for many. The debate on how to proceed also continues, with renewed vigor since the 2016 elections. There have been attempts to repeal and replace the ACA in Congress. Thus far these more drastic attempts to alter the current system have failed; but needless to say, healthcare reform remains a very dynamic topic.
Tips for the Interview
So how about that interview? I will leave you with these tips:
1 | Know the Factors Driving Healthcare Reform
Understand some of the basic challenges facing healthcare in the United States, and how these continue to motivate reform.
2 | Understand the Fundamentals of Obamacare (the ACA)
Develop a working knowledge of the most significant portions of the ACA (like those discussed above). Be able to discuss them in brief.
3 | Think About Your Opinions on Healthcare Reform Issues
While you should avoid overly politically charged statements in your interview, it is also important to explore your own thoughts on how to address challenges in healthcare. Developing these values is a key part of your training, and displaying some thoughtfulness will always be a plus.
4 | Understand the Existing Opinions of the Medical Field
It is also worth knowing that major medical organizations and professional societies publish frequently on these topics. If you’re looking for a general overview from the physician’s perspective, the American Association of Medical Colleges and American Medical Association have both clearly stated their priorities with regards to healthcare reform.
Healthcare is a changing landscape. With your enthusiasm and ingenuity, it is also one you can aspire to change for the better as a future physician.
The topics discussed here will help you gain a better understanding of healthcare policy and reform as it exists in the US today. It will also prepare you to discuss these topics as they come up on interview day. Do not hesitate to consult our interview preparation services if you would like further practice with this topic or any other related to the medical school interview. Best of luck this Fall!