Medical Students and the Affordable Care Act: Uninformed and Undecided

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 toward the ACA and to examine the relationship between these attitudes and respondents' political affiliation, medical school year, specialty choice, and financial considerations.

In January 2011, we e-mailed an online survey to all 1235 Minnesota medical students at the 3 medical campuses in Minnesota. Three subsequent reminders were sent to nonresponders. 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 3 questions regarding the ACA using a 5-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.”

A total of 843 of the 1235 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. Most respondents agreed that physicians are professionally obligated to play a role in implementing the ACA (69%). Most students also indicated that monetary considerations influenced their choice of specialty (53%) (Table).

In unadjusted analyses, there was a significant association between understanding of and support for the ACA (P < .001); 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 with 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 (odds ratio [OR], 15.1 [95% CI, 8.6-26.8]; OR, 2.2 [95% CI, 1.4-3.3]; and OR, 3.3 [95% CI, 2.1-5.1], respectively). 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 [95% CI, 0.4-0.7]; OR, 0.7 [95% CI, 0.5-0.9]; OR, 0.6 [95% CI, 0.4-0.8]). Compared with 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 [95% CI, 0.3-0.9]; OR, 0.6 [95% CI, 0.4-0.99]). Third-year students, compared with first-year students, were less likely to agree that physicians are obligated to play a role in implementation of the ACA (OR, 0.6 [95% CI, 0.3-0.9]).

In this analysis of medical students' knowledge and attitudes toward the ACA, 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 reflect previous research demonstrating insufficient policy education in medical school and suggest that increasing such efforts may be required for successful implementation of the ACA and future health care reform initiatives.^6,7

Correspondence: Dr Winkelman, Department of Internal Medicine and Pediatrics, University of Minnesota, MMC 913, 420 Delaware St SE, Minneapolis, MN 55455-0341 (wink0137@umn.edu).

Published Online: September 24, 2012. doi:10.1001/archinternmed.2012.3758

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, Antiel, and Song. Acquisition of data: Winkelman. Analysis and interpretation of data: Winkelman, Davey, Tilburt, and Song. Drafting of the manuscript: Winkelman and Antiel. Critical revision of the manuscript for important intellectual content: Winkelman, Antiel, Davey, Tilburt, and Song. Statistical analysis: Davey and Song. Obtained funding: Davey, Tilburt, and Song. Administrative, technical, and material support: Winkelman, Antiel, Davey, and Tilburt. Study supervision: Winkelman, Antiel, and Song.

Funding/Support: This study was supported by grant No. UL1RR024150 from the National Center for Research Resources, National Institutes of Health (NIH). Dr Tilburt received support for this research from the NIH 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.

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, MD, for contributions in survey development and literature review (Alameda County Medical Center); Shailendra Prasad, MD, MPH, for policy opinion and contributions in survey development (University of Minnesota); and Mark Winkelman for contributions in survey development (Winkelman Consulting). They received no financial compensation for their contributions.