ACA: Don’t throw the baby out with the bath water
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As the new administration looks at ways to repeal or fix the Affordable Care Act (ACA), those of us in the business of health care and medical education hope these changes will not gut what is good about the current system.

In addition to providing coverage for 20 million people, health care reform has changed the way we look at health care delivery and placed a priority on prevention. For me, one of the biggest successes of the ACA is its commitment to training primary care physicians, who are in increasingly short supply as many medical students choose more lucrative specialties.


The Association of American Medical Colleges estimates that there will be an overall shortage of up to 90,000 U.S. physicians by 2025, and it is increasingly more difficult to attract physicians into primary care practices. Part of the reason is financial. The 2016 Physicians Compensation Survey found that nearly 40 percent of surgeons who responded made more than $450,000 per year; only 2.3 percent of family medicine practitioners were in that income bracket. The New England Journal of Medicine reported a $3.5 million difference in income between sub specialists and primary care physicians over a 35 to 40 year career.

That may explain why in 2016, just 14.5 percent of medical school seniors went to primary care residencies. According to the American Association of Family Practitioners, which used National Resident Matching statistics to track the growth rate of medical specialties from 1986 to 2016, emergency medicine positions grew by 602 percent during that time period, while family medicine positions increased by only 35 percent. 

The Teaching Health Center Graduate Medical Education Program, a five-year, $230 million initiative, was created by the ACA to increase the number of primary care residents trained outside hospitals in community-based settings. Funding is set to expire on Sept. 30, 2017.

Teaching Health Centers are good for everyone. They keep people out of hospitals, provide health-care access to patients who are underserved, and place primary care doctors in a setting where they can appreciate the impact of their work. Many studies have shown a correlation between access to primary care and better health outcomes for people with chronic conditions such as heart disease, diabetes and high blood pressure, as well as lower mortality rates and health care costs.

These centers also address a fundamental flaw in the way we train these doctors. Surprisingly, teaching hospitals often play a role in derailing the career of a future primary care practitioners. Residents who aspire to careers in primary care often change their minds after working alongside specialists who have higher salaries and are more valued by hospitals as revenue generators. Research has found that residents who train at Teaching Health Centers are better prepared to practice primary care and more likely to do so.

Medicare covers the majority of the cost teaching hospitals spend on training residents. Despite increasing demand, it’s been 20 years since the Balanced Budget act of 1997 capped the number of residency slots paid for by the federal government through Medicare.

That means if a hospital has funding for 100 slots but needs 110, it must pay for the 10 additional residents. Though patient care has shifted its emphasis to wellness and prevention, the current reimbursement system is based on the number of procedures performed, incentivizing hospitals to fund additional residencies in revenue-producing specialties instead of primary care.  

The dismantling of the ACA could leave as many as 18 million people without health insurance. Let’s not lose sight of the fact that there is a dwindling number of physicians who might be available to care for them.

Bruce Koeppen, MD, is Founding Dean of The Frank H. Netter MD School of Medicine At Quinnipiac University

The views expressed by authors are their own and not the views of The Hill.