奥巴马的医疗政策对美国医生有什么好处

Introduction

Re-electing President Barack Obama and continuing his policies would be better for physicians because millions more Americans will have insurance and be able to pay for healthcare and preventive services, say many physicians who support Obama. Additionally, administrative costs and hassles of dealing with insurers will be reduced, and doctors will play a leading role in new delivery systems to improve care and reduce costs.

Many physician supporters of Obama also believe that Obama's economic and tax policies are better for doctors overall -- even if some doctors have to pay higher income taxes -- because those policies will help build a society with a stronger middle class and fewer social problems. And they believe that he would protect public investments in medical research and public health while Mitt Romney's budget plan might slash such spending.

Physicians who back Obama base their support largely on his comprehensive healthcare reform law, the Affordable Care Act (ACA). Although some would have preferred a single-payer, Medicare-for-all model, they say that the ACA finally will move the nation forward in addressing the longstanding problems of lack of healthcare coverage and access, rising costs, quality-of-care gaps, and poorer population health than in other advanced countries.

Like it or not, they say, there's no way to ensure that Americans with preexisting medical conditions can get private insurance without the controversial ACA provision requiring nearly everyone to have insurance, just as there's no way to make insurance affordable to lower-income people without the ACA's subsidies.

"I firmly believe what's best for physicians is getting everyone insured," says Mario Motta, MD, a Salem, Massachusetts, cardiologist who's a member of the American Medical Association House of Delegates. "Whatever person or party gets us to universal healthcare, that's who I have to support because that's what's best in the long run." He believes that the ACA's private insurance expansion is the only way to avoid a "complete government takeover" of health insurance, which he opposes.

In contrast, Mitt Romney's proposals to repeal the ACA and deregulate health insurance would sharply increase the number of uninsured and put even greater financial pressure on physicians. A recent Commonwealth Fund study^[1] projects that the number of uninsured Americans under Romney's proposals would soar to 72 million by 2022, while dropping to 27 million under Obama's ACA law. Among nonelderly Americans, 22% would be uninsured in 2022 under Romney's plan, compared with 10% under Obama's law.

Taking Care of Ill Patients

Many pro-Obama physicians were appalled at Romney's recent comments that uninsured Americans can always get care in the hospital emergency room and that "we don't have people that become ill, who die in their apartment because they don't have insurance."

"It's really hard to take care of patients when they can't afford their pills or their treatment plan; they delay care until they have to go to the ER, and they skip doctor visits," Dr. Motta says. "All of that is directly attributable to the fact that they don't have insurance. We've pretty much solved that in Massachusetts."

He leans toward Obama but appreciates the Massachusetts coverage expansion law that Romney as governor helped pass, which was the model for the ACA. He's greatly disappointed that Romney has distanced himself from the Massachusetts reform model.

"The president's health plan is certainly better for doctors than having 72 million people without health insurance," agrees Rep. Jim McDermott, MD (D-Wash), a psychiatrist who represents the Seattle area and is a longtime sponsor of Medicare-for-all legislation. "It makes it possible for another 30 million people to have insurance and get preventive care. Doctors don't want to just treat catastrophes; they want to help people be well. That's a major step forward. Romney's alternative is a disaster."

Controlling Costs vs Free Market

Doctors who back Obama believe that the president's regulated-market reform model stands a better chance of controlling costs and preserving smaller physician practices than Romney's deregulated, free-market approach. They note that under the current competitive system, large hospital systems and insurers already are squeezing out independent doctors. And they contend that healthcare can never be a normal market because people don't have enough information to shop for plans and providers, and sick people aren't in a position to shop around.

Obama's reform law establishes a regulated competition system for private insurers who, starting in 2014, will sell standardized benefit plans to individuals and small groups through new state health insurance exchanges. Insurers will have to accept all applicants regardless of preexisting conditions, with limited price variations based on age. In contrast, Romney wants to encourage more insurers to compete and offer a wide range of benefit packages, without having to meet state benefit mandates or accept applicants who haven't had continuous coverage.

"The insurance exchange is good for doctors because then you've got a couple of health plans people will buy, and that cuts down on doctors' back-office work," Dr. McDermott says. "It's a big drag on your office to have to take care of 25 different insurance firms and have all this paperwork. Doctors just want to take care of their patients and get paid."

Independent Doctors

Other Obama supporters note that the current free-market model is hurting independent doctors who lack bargaining leverage, with many opting to work for hospital systems and larger groups. "Left on its own, the market will kill small private practice, no matter what doctors want to believe," says Robert Berenson, MD, a general internist and health policy fellow at the Urban Institute in Washington, DC.

In contrast, he points to the Accountable Care Organization (ACO) demonstrations launched under the ACA, which lets groups of private physicians band together to streamline care for beneficiaries in traditional Medicare and share in any cost savings if they meet quality targets. Many ACOs have been started by physician-led groups without hospital involvement.

"The ACA set up tests of alternative payment approaches that put doctors back in control of their fate," Dr. Berenson says. "So I think the law provides promise of a better healthcare system in which doctors will have greater satisfaction in their practice."

Obama's approach to Medicare and Medicaid is also better for doctors, Obama supporters argue, because he will preserve the programs as guaranteed benefits, providing patients with certainty that they'll have access to care when they need it. In addition, his reform law enhanced Medicare's preventive and drug coverage and extended the solvency of the program. In contrast, Romney's Medicare voucher proposal means that people "don't know whether they'll have access to affordable care when they are old and sick," says Steve Kagen, MD, an Appleton, Wisconsin, allergist and former Democratic congressman who's proud of his vote for the ACA, which he calls the most important legislation in a century.

Similarly, he adds, Romney's Medicaid block grant plan would "allow states to turn their back on people in need. What kind of nation would we be if we turned our back on children who are ill? By not paying providers their overhead for taking care of people in need, you're turning your back on the community and on providers delivering lifesaving care."

Effect on Society Beyond Doctors

More broadly, physicians who support Obama feel that his economic policies are better for all Americans, and that's good for doctors. "As doctors, we're dependent on a successful middle class, and our best opportunity is expanding the middle class," Dr. Kagen says. "In my view, Obama has the best plan to expand the middle class, by investing in education, clean energy, and infrastructure. Then I'll do better."

Dr. Berenson adds that even though physicians might benefit financially from Romney's proposals to cut taxes for wealthier Americans, "they wouldn't be very happy with a society marked by increasing disparities between the rich and poor, more crime, and more demands on public funding for food and shelter. That's not a world I want to live in."

Regardless of their tax bills, he says that doctors' professional interests lie more with Obama and the Democrats because "at least Democrats are trying to do something about the obvious problems in the healthcare system, while I've seen no evidence that Romney and the Republicans have any views of what should happen. Romney passed a very good law in Massachusetts, he's proud of it, but he can't tell anyone because his party is so Neanderthal on the issue."

The bottom line is that doctors who back President Obama strongly prefer his focus on ensuring that all Americans have access to healthcare and a way to pay for it. "I assume doctors mostly go into the profession because they want the personal satisfaction of improving the health of the public," Dr. Berenson says. "The obvious benefit of Obama's law is that it sets up an environment where doctors can feel proud that they are working in the health system."