How do medical students feel about health care reform?

In September 2011, researchers surveyed 1,232 medical students at ten schools across the nation about their opinions on the Affordable Care Act (ACA). Four out of five students (80.1%) indicated their support. Meanwhile, the American Medical Student Association has officially and emphatically voiced its support of the ACA and celebrated the Supreme Court decision that upheld it.

Why the overwhelming support? Let’s run through some possibilities.

1. Do medical students believe the ACA will improve quality of care? Surveyors asked students to agree or disagree with the following statement: “The PPACA will improve health care quality.” Only 31.4% agreed. The rest disagreed (20.9%) or were undecided (47.7%).

2. Do medical students believe the ACA will contain costs? Here, a mere 18.6% of students agreed. Nearly double (36.0%) disagreed, while the remaining 45.4% were undecided.

3. Do medical students believe the ACA will expand access? Here’s where the answers shifted dramatically. Slightly over two out of three students (67.6%) agreed, compared to only 6.5% disagreeing and 25.9% remaining undecided. That means students were over twice as likely to believe the ACA will expand access as they were to believe it will improve quality of care, and over 3.5 times as likely to believe this statement than the one on cost containment.

Finally, there’s a less obvious option.

4. Do medical students feel they should support reform, without good reason? Surprisingly, only a little over half (53.9%) said they understood the major provisions of the ACA. Meanwhile, nearly a third (30.2%) felt they did not understand, while 15.9% were undecided.

That last finding raises an interesting question. How can four out of five students be in favor of something if only half understand what it’s about? The same critique can go in the other direction; it would be just as silly to oppose something one doesn’t understand as it would be to support it. Part of the discrepancy could be due to a bug in the survey design. When the authors asked about support for the ACA, they did not offer an “undecided” answer – meaning if there were those who didn’t want to take a stance because they felt they didn’t sufficiently understand the provisions, there was no place to express it. However, there was an undecided option in response to the statement “The American health care system as it exists today needs to be reformed.” Very, very few marked it. Rather, 94.8% agreed.

Taken together, these stats hint at a possibility that some students may be driven by a fervent reform desire to support any action forward, even if they are not completely clear on the details of what that action will entail. Before we come down too harshly on them, it is worth noting that others have applauded the idea of taking action, even in the face of uncertainty. As Atul Gawande put it:

“The reality of trying to solve a wicked problem [like health care] is that action of any kind presents risks and uncertainties. Yet so does inaction. All that leaders can do is weigh the possibilities as best they can and find a way forward. They must want to make the effort, however. That’s a key factor.”

But that’s not to say there isn’t a problem. There is a difference between accepting uncertainty of outcome and not knowing what the provisions state in the first place, and we would hope, of course, that those going into the medical profession would be knowledgeable about the terms of the policies they will soon be practicing under. Yet the study showed that medical students are surprisingly on par with the rest of the U.S. population in terms of understanding the provisions of the ACA. As a result, some are calling for more education in health policy. My school is somewhat unique in that all first-years take a required course in the subject, but we are not the norm. In the absence of formal education, medical students tend to get their information the same ways everyone else does – through media coverage, blogging, and other forms of personal information seeking.

So why do most medical students, at least the ones surveyed here, support the ACA? The results suggest that the issue of access to care provides stronger grounds for support than issues of quality and cost containment. But we also can’t rule out the troubling possibility that some might not have a good reason at all.