To the Editor
Although President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) on March 23, 2010, it remains widely debated and is a defining issue in the upcoming 2012 presidential and general elections.1 The success or failure of the ACA will lie in its acceptance, as well as the effectiveness of its implementation.2,3 While the next generation of physicians will play an increasingly significant role in the implementation, modification, and advocacy for or against reform measures, it is unclear whether they possess the knowledge or will to participate in such efforts.4,5
We sought to characterize medical students’ knowledge of and attitudes towards the ACA and to examine the relationship between these attitudes and respondents’ political affiliation, medical school year, specialty choice, and financial considerations.
METHODS
In January 2011, we emailed an online survey to all 1,235 Minnesota medical students at the three medical campuses in Minnesota. Three subsequent reminders were sent to non-responders. The institutional review boards at the University of Minnesota and Mayo Clinic approved the study.
Students were asked to indicate their level of agreement to three questions regarding the ACA using a five-point Likert scale: “I understand the basic components of the Patient Protection and Affordable Care Act (the national health care reform bill passed in March 2010)”; “I support the Patient Protection and Affordable Care Act”; and “Physicians are not professionally obligated to play a role in implementing the new healthcare reform bill”. Independent variables considered were demographic characteristics (including medical school year); anticipated specialty type, categorized as primary care, surgery (including surgical subspecialties), procedural specialty, nonprocedural specialty, and nonclinical specialty; political self-characterization (liberal, moderate, conservative); and response to the statement “Medical school debt and potential earnings have or will influence my choice of specialty.”
RESULTS
Eight hundred forty three of the 1,235 medical students in Minnesota responded to the survey (68%). Medical students in the sample predominantly identified themselves as liberal (55%), and more than half (52%) anticipated a primary care specialty.
Fewer than half of the respondents (48%) agreed with the statement, “I understand the basic components of the Patient Protection and Affordable Care Act.” A large minority (41%) of students had no opinion regarding support for the ACA and only 13% of students did not support the legislation. A majority of respondents agreed that physicians are professionally obligated to play a role in implementing the ACA (69%). A majority of students also indicated that monetary considerations influenced their choice of specialty (53%) (Table).
Table.
Opinions About Healthcare Reform Statements From Medical Student Respondents
| Disagree/Strongly Disagree | No Opinion | Agree/Strongly Agree | |
|---|---|---|---|
| I understand the basic components of the Patient Protection and Affordable Care Act (the national health care reform bill passed in March 2010). | 331/839 (39.5 %) | 102/839 (12.2 %) | 406/839 (48.4 %) |
| I support the Patient Protection and Affordable Care Act. | 105/841 (12.5%) | 345/841 (41.0%) | 391/841 (46.5%) |
| Physicians are not professionally obligated to play a role in implementing the new healthcare reform bill. | 582/840 (69.3%) | 174/840 (20.7%) | 84/840 (10.0%) |
| Medical school debt and potential earnings have or will influence my choice of specialty.a | 301/833 (36.1%) | 92/833 (11.0%) | 440/833 (52.8%) |
Responses to this question were controlled for in multiple logistic regression models
In unadjusted analyses, there was a significant association between understanding of and support for the ACA (p < 0.0001); 72 % of those who understood the ACA indicated support for the ACA, while 20% who did not understand the ACA indicated support. Most students who did not understand the ACA indicated no opinion (72%) regarding support, while only 11% of students who understood the ACA had no opinion about support.
In multiple logistic regression models, self-identified liberal students, compared to conservative students, were significantly more likely to have a positive response regarding their support for, understanding of, and sense of obligation to implement the ACA (OR=15.1 (8.6–26.8);OR=2.2 (1.4–3.3);OR=3.3 (2.1–5.1)). Students who indicated that their choice of specialty was or would be influenced by medical school debt or future earnings were significantly less likely to agree that they supported, understood, or felt a sense of obligation to implement the ACA (OR=0.5 (0.4–0.7);OR=0.7 (0.5–0.9);OR=0.6 (0.4–0.8)). Compared to students who anticipate a primary care specialty, students who indicated their future specialty as surgical or undecided were significantly less likely to indicate support for the legislation (OR=0.6 (0.3–0.9);OR= 0.6 (0.4–0.99)). Third year students, compared to first year students, were less likely to agree that physicians are obligated to play a role in implementation of the ACA. (OR=0.6 (0.3–0.9)).
COMMENT
In this analysis of medical students’ knowledge and attitudes toward the Affordable Care Act, we found that future physicians remain largely ignorant and indecisive about the ACA, with a minority of respondents indicating understanding and 41% of students indicating no opinion regarding their support of the legislation. Despite these views, most students (69%) endorse a professional obligation to implement the ACA. Responses to all statements varied significantly by political affiliation and influence of debt and future earnings on anticipated specialty. Furthermore, support for the ACA varied significantly by anticipated specialty, and opinions regarding professional obligation varied significantly by medical school year.
While future physicians believe they have a responsibility to participate in implementing the ACA, these data raise concerns that they may not possess the knowledge necessary to implement reform measures in the coming years. Our data reflects previous research demonstrating insufficient policy education in medical school and suggests that increasing such efforts may be required for successful implementation of the Affordable Care Act and future health care reform initiatives.6,7
Acknowledgments
Funding/Support: The project described was supported by Grant Number UL1RR024150 from the National Center for Research Resources, National Institutes of Health. Dr. Tilburt received support for this research from the National Institutes of Health R01 (AT06515, U10 CA149950), the Greenwall Foundation Faculty Scholars Program, the Mayo Clinic Foundation Early Career Development Award, the Center for the Science of Health Care Delivery at Mayo Clinic, the Mayo Clinic Center for Translational Sciences Activities (CTSA) and the Mayo Clinic Program in Professionalism and Ethics.
Footnotes
Author Contributions: Dr. Winkelman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Winkelman, Song. Acquisition of data: Winkelman. Analysis and interpretation of data: Winkelman, Antiel, Davey, Tilburt, Song. Drafting of manuscript: Winkelman. Critical revision of the manuscript for important intellectual content: Winkelman, Antiel, Davey, Tilburt, Song. Statistical analysis: Davey. Administrative, technical, and material support: Winkelman, Antiel, Davey, Tilburt, Song. Study supervision: Winkelman, Song.
Conflict of Interest Disclosures: None reported.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Additional Contributions: We thank Erik S. Anderson, M.D. and Molly O’Leary for contributions in survey development and literature review (University of Minnesota); Shailendra Prasad, M.D., M.P.H. for expert policy opinion and contributions in survey development (University of Minnesota); and Mark Winkelman for contributions in survey development (Winkelman Consulting). There was no financial compensation for their contributions.
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