The U.S. Supreme Court upheld the major portions of healthcare reform in a 5-4 decision in June 2012. Now that the U.S. elections have concluded—thus eliminating the possibility of a Romney government, and presumably meaning that so-called Obamacare is likelier to be here to stay—it's a good time to ask what the legislation means for medical education and for physicians' careers.
The Affordable Care Act (ACA) has recently triggered a debate within the medical community about both its potential impact on medical trainees and on practicing physicians. While the president of the American Medical Student Association has publicly supported the changes in a recent official memo, a recent survey indicates that 40 percent of medical students may not even be aware of the provisions of the act.
Institutional changes can often be double-edged swords, and this series of proposed changes is no different. There are both potential benefits and downsides to what is now widely seen as almost inevitable healthcare reform.
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There are two potentially positive outcomes:
1. More medical students may be drawn to primary care specialties. With a new emphasis on higher reimbursements for primary care specialties, including internal medicine and family medicine, the direction of medical education could be affected. A prominent healthcare economic think tank posits that healthcare reform will expand scholarships and loan repayment programs in order to draw medical students into primary care specialties. Not so long ago, many medical graduates were drawn into subspecialties.
This could also cause a shift in medical school elective selection down the line, with competition for previously popular subspecialty electives shifting to primary care ones. It is thought that these changes would not only improve access and funding for preventative care, but that they are also popular with many current medical students.
2. There will be more admissions slots at existing schools, and more medical schools. For the first time since the 1990s, there are 18 medical schools in the United States in various stages of accreditation and development. Eleven have opened since 2007, and enrollment in both allopathic and osteopathic medical schools has expanded in recent years. The Association of American Medical Colleges has also said that a record number of minority students enrolled this past year.
There are also a couple of potential downsides:
1. The larger number of M.D.'s will compete for the same number of residencies. Though the ACA has expanded the number and diversity of U.S. medical graduates, the number of residency spots, funded by Medicare, has remained unchanged since a Congressional Balanced Budget Act took effect in 1997. A larger number of U.S. medical graduates could find themselves unmatched after graduation; in fact The Chronicle of Higher Education reported that Texas, which ranks 42nd in the United States in the number of doctors per 100,000 people, will graduate more medical students than it has residency slots available by 2014.
2. Physicians may elect to work fewer hours, thus decreasing access to care. A report issued by the Kellogg School of Management at Northwestern University indicates that portions of the ACA, specifically addressing cost containment and Medicare reimbursement, may end up ultimately decreasing the access to care. Based on data obtained after the establishment of the State Children's Health Insurance Program (SCHIP) in 1997, the report concludes that the program expanded access, but it eventually led to shorter patient visits and to significant numbers of physicians electing to work fewer hours.
The report cites previous expansions of public health programs in the United States and Canada and concludes that physicians probably elected to work fewer hours due to declines in reimbursements. The report speculates that this could lead to a future drop in the quantity and quality of medical school applicants, as the field may become less enticing. Further research would be needed to determine this definitively, the report adds.
Ibrahim Busnaina, M.D. is a graduate of the University of Pennsylvania School of Medicine and coauthor of "Examkrackers' How to Get Into Medical School." He has been consulting with prospective medical school applicants, with a special focus on minority and other nontraditional candidates, since 2006.