Repealing Obamacare Will Seriously Disrupt How Doctors Work

It has the potential to hurt not only doctors’ abilities to treat their patients, but also their income.

Jan 12 2017, 2:00pm

Image: Pixabay

Not all of the news coming out about President-elect Donald Trump is of life or death importance. But for individuals with serious illnesses, and the people treating them, what he decides to do with Obamacare really is a matter of survival.

One of Trump's biggest campaign promises was to repeal and replace the Affordable Care Act, also dubbed Obamacare, a major and contentious piece of health care reform that enabled 20 million more Americans to get health insurance coverage. But he hasn't yet made it clear what he wants to replace it with, leaving doctors nervous.

The uncertainty is worrisome because while many doctors aren't satisfied with the ACA, they also don't want to lose the progress that's been made, and repealing all or part of Obamacare has the potential to hurt not only doctors' abilities to treat their patients, but also their income.

Doctors faced a lot of changes as the ACA was rolled out, from the way they practice medicine and prescribe drugs to the kinds of patients they see. And not all of them are fans of the legislation. A 2016 survey of more than 17,000 physicians conducted by the Physicians Foundation, a nonprofit that advocates for doctors, found that the majority of US doctors graded Obamacare with a C, D, or F for how well it drove healthcare reform.

The percentage of physicians in each category that gave the ACA an A or B. Image: Physicians Foundation

Part of this has to do with money. The ACA shifted some of the ways doctor's treatment is assessed and compensated, and doctors worried about losing money after the changes. Insurance companies used to rely largely on a fee-for-service model, where the more work a doctor did, the more she or he was paid. This meant doctors could make a lot of money by prescribing procedures and scans to their patients. But the ACA created a number of different pay models that were meant to focus on quality over quantity.

"[Under Obamacare] there were now rewards for meeting quality benchmarks. For instance: how well-controlled were the blood sugar levels of patients with diabetes," said Dr. Benjamin Sommers, an associate professor of health policy and economics at Harvard's T.H. Chan School of Public Health.

There were also new penalty payments when health care providers were considered not up to snuff, Sommers explained. If too many Medicare patients were repeatedly readmitted, for example, hospitals could lose money. Sommers told me it's unclear if these models would be removed, even if Obamacare was completely dissolved, because there have been other legislation pushing forward these changes, such as the Medicare Access and CHIP Reauthorization Act of 2015. But without knowing Trump's plan, it's impossible to say if his pay models would be better or worse.

"You write prescriptions for medications, and the patient may not be able to afford them."

Repealing Obamacare could cost doctors money in other ways, too. Though Trump's team has promised no one will lose their insurance, without knowing what changes are coming, there's still a risk some portion of the 20 million newly-insured Americans will lose coverage, making it difficult for doctors to avoid gaps in treatment while also potentially hurting their income.

In the past, doctors would often offer discounted or free care to patients who were uninsured and couldn't afford to pay costs upfront, according to Dr. Jeffrey Cain, the president of the American Academy of Family Physicians (AAFP), in a 2013 Medscape story on how Obamacare would impact doctors. In these circumstances, insurance coverage helped both parties.

"This new coverage will mean that family physicians can have a financially viable practice," Cain said.

Patients losing coverage would also make it more difficult for doctors to continue providing care. Sommers told me this is the single most important concern: when patients with chronic issues lose coverage, or don't see a doctor regularly, their diseases can become both dangerous and expensive.

"You write prescriptions for medications, and the patient may not be able to afford them," Sommers said. "You need them to get some testing done, and they may not be able to pay for it. Some of them have complicated problems and need to see a specialist, and they may not be willing to go because they can't pay for it or a specialist might say 'I'm not taking somebody who doesn't have insurance.'"

To completely repeal Obamacare, Trump would need 60 votes in the senate. The GOP only holds 52 senate seats, and even within the party there's a growing resolve to not repeal the ACA without something set up to replace it. However, Republicans can push through legislation in the budget—which only requires a simple majority to pass—to repeal some parts of the ACA, including funding for Medicaid expansion, which has extended coverage to millions of low-income families.

Many doctors are eager for more health care reform, but from both a Hippocratic and a financial point of view, it's concerning to face an uncertain future where change is certain but progress is not guaranteed.