What doctors think about the Affordable Care Act

"I love medicine. Medicine is great," Hill says with a big smile. "When you sit in the exam room, interact with patients, you operate, you do those things that we were trained to do. It's awesome."

The smile disappears. "When we have to deal with the industry of health care, when I have to deal with all of the bureaucracy and the burden that's built around the system of health care, that makes medicine difficult."

And how does Hill feel the Affordable Care Act affected that bureaucracy?

"I thought it was going to be a disaster. And I was right."

Doctors have long complained about any rules and regulations that take them away from providing care for their patients. But for Hill, the Affordable Care Act took things too far.

"The ACA took this terrible broken health care system and added a lot of burden onto physicians," Hill says. "We're losing the focus of who we're supposed to be taking care of: the patient. You're not my customer anymore. Now, I've got to respond to the federal bureaucracy, not you."

Jamie Thomas hears a similar refrain from doctors every day. He's the vice president of recruiting for the Atlanta office of the Medicus Firm, which places physicians in new jobs.

"Older physicians or physicians that have gone into it as a passion want to have the continuity of care for their patients that I think they feel is jeopardized in this system," Thomas says.

"They tell us the Affordable Care Act has negatively affected their reimbursements, there are added non-clinical duties and paperwork, and they've got to see more patients to keep up with expenses. And it kind of drives their practice away from how they've created it, which was spending time with patients."

In Dayton, Ohio, family doctor Dr. Arvin Nanda has a different take.

Even though his practice of 18 years can't afford to take patients on Medicare and make ends meet, he still sees a significant benefit from the legislation.

"The Affordable Care Act has been beneficial to the poor, less fortunate in our city. They cannot afford medications, treatment and testing," says Nanda.

"The ACA was never meant to be a finished product. It was meant as a place to start by covering more people with health insurance."

Nanda echoes the stance of many of the major medical associations, which have sent letters to President-elect Donald Trump asking him not to repeal the Affordable Care Act without a solid replacement in place.

"Simply repealing the ACA and being devoid of regulation will allow insurance companies to achieve profits over the health care of most Americans," Nanda said. "At a time when obesity, diabetes and heart disease are prevalent in our country, should we trust insurance companies to aid us in confronting disease? I think not."

Nanda's point of view is more common among primary care doctors, especially those who work in safety net settings -- providing care to the uninsured, people on Medicaid and vulnerable populations -- or places where they have frequent interactions with patients struggling to afford care, says Dr. Benjamin Sommers, an internist and health economist at the Harvard T.H. Chan School of Public Health.

"They see more patients now who have health insurance, who can afford their prescriptions, who can come in to be seen," Sommers said. "Meanwhile, doctors who see mostly patients with private health insurance are much less likely to have seen these benefits."

He adds that "some patients could even be struggling with aspects of their health insurance from the Affordable Care Act. So you get kind of a polarized view of the law, because each doctor is seeing a smaller part of the big picture."

It turns out that it's difficult to quantify what most doctors really think of Obamacare.

"Doctors tend to be a difficult group to survey and get their opinions in a really scientific sort of way," says Sommers. He points to a 2015 poll by the Kaiser Family Foundation and the Commonwealth Fund (PDF) that looked at the experiences and attitudes of primary care physicians during the first year of ACA coverage expansion.

"Like much of America, doctors are divided by ideology, by party," Sommers says. "We see more positive views toward the Affordable Care Act among liberal and Democratic-leaning doctors, and we see more skeptical views among conservative and Republican-leaning doctors."

Most other surveys of doctors are not much better than anecdotes, says Sommers, because thousands are polled, but only the most passionate or frustrated respond.

Still, they provide an interesting snapshot of what is on those vocal doctors' minds, such as Medicus' 13th annual Physicians Practice Preference and Relocation Survey.

In 2016, this survey was sent to 10,000 randomly selected doctors from the firm's database of 100,000 physicians. There were 2,314 doctors who responded, representing more than 21 specialties and 50 states.

Fewer than 3% of respondents awarded the ACA an "A," the survey found.

A 2016 survey by Merritt Hawkins for the Physicians Foundation found similar results. Only 3.2% of physicians gave the Affordable Care Act an "A" grade, down from a more favorable rating in 2014. Most physicians gave the law a "C."

Age also seems to play a role in how doctors might view the Affordable Care Act. Sommers reviewed some of the studies that have looked at attitudes among medical students and young physicians.

"What we found was a consistent pattern that younger physicians were generally more favorable towards the Affordable Care Act and more supportive of the idea that the government has a role to play in helping citizens afford their access to health care," explains Sommers.

"Older physicians, not all but many, are more opposed to the notion that the government has a responsibility here and often are more likely to report frustration with changes in how medicine is delivered."

Sommers thinks some of this relates simply to what they're used to.

Thomas sees the same trend among the residents and younger doctors his firm tries to place.

"If you think about it, younger physicians, from residency and fellowship programs to five, six years out, this is all they know," he says. "I think that the Affordable Care Act and some of these changes that it has created has been a positive for those folks."

For example, the increase in patient access to health care has created a boom in hospital-based jobs, which are often more lucrative, require fewer hours and offer doctors a large administrative staff to assist with paperwork and coding regulations.

"Over 70% of residents and fellows that we polled last year indicated that the most important aspect to their job search was a quality of life or work-life balance," says Thomas.

"Older physicians tell us that they entered into medicine more as a calling, more as a passion, where younger physicians look at it as it's more of a career."

For Hill, hanging out his own shingle was a calling.

"I always wanted to be a doctor," he says with a chuckle. "It was one of those things I wanted ever since I was a young child."

But last year, he and his partners gave up their years of private practice to become partners with Northside, a large Atlanta-based hospital system.

Northside declined to be interviewed for this story.

For Hill, it was a long, hard path to arrive at such a painful decision, which started in 2010 when he and another group of doctors consolidated to reduce expenses.

"You see, our employees get paid first, the overhead gets paid first, the bills get paid first, and then we get paid," says Hill. "And we were going through months where that wasn't happening; we weren't getting paid."

Then came the Affordable Care Act with its set of rules and regulations, and additional administrative overhead.

"I look at my office, and I've got a coder, I've got a biller, I've got someone who works on prior authorization, pre-certification, claims denial processes, quality care questions, discussing with an insurance company how we get paid.

"And it got to the point where we were really starting to look at ourselves, and we were working harder and harder, working longer and longer hours, and we just said, 'We just can't keep up with the administrative burden.' "

So like a growing number of private practice physicians, Hill joined forces with Northside and saw immediate benefits.

"It's all about clout. They have greater leverage in the marketplace and negotiate a better contract with insurance companies than I can."

While the new partnership with Northside has reduced Hill's costs, he worries about his patients, as the cost of health care continues to rise.

"Copays are going up. Deductibles are going up," frets Hill. "So while they can go and see me in my office at a copay of $50, if they need a procedure that's going to cost $1,800 or $2,000 or $4,000 to do, and they have a $6,350 deductible that you often see on the silver plans on the exchange, they go, 'I can't afford it.' So they don't get the care they need."

He's not alone in his concern. The Kaiser-Commonwealth study found that four of 10 providers "believe the ACA has had a negative impact on patients' out-of-pocket costs."

The Great American Physician Survey, done every year by Physicians Practice, a division of UBM that provides information and advice to physicians in private practice, found doctors worried about another backlash: patient payments.

In the survey, 45.1% said they were having problems collecting large deductibles from patients, while 23.8% were seeing claims denied due to a patient's non-payment of premiums.

Hill doesn't blame the Affordable Care Act for all of medicine's woes. He knows the trend toward consolidation has been around for some time, with physicians struggling with non-ACA regulations, such as implementing electronic health records and new coding rules, as well as realities of the health care marketplace.

"Even before the Affordable Care Act, even before a lot of the legal changes that came down, health care was in need of a fix," says Hill. "We didn't fix it. We just made it worse."

He wants to see the act repealed but doesn't want it replaced with more of the status quo, where hospitals and insurance companies are the winners.

"I think we, as physicians, have dropped the ball. We've given up our role," says Hill. "Our role should be the caretakers of health care, and instead we gave that to the insurance companies. We got other people to step in. We've got to look at a way to allow physicians to innovate, to change, to bring forward a better product than what's out there right now."

For Hill, this means it's time for doctors put on their entrepreneurial hats and take back the business of medicine.

He's currently working on an idea about telemedicine, and he points to transparent pricing and a movement toward "concierge medicine," in which doctors bypass insurance and charge a set rate to be readily available to patients. He believes this could make the doctor/patient relationship a priority and reduce cost.

"Why do I need 535 people in Washington, D.C., to fix things?" asks Hill.

"There are people out here that love health care, that love providing care for their patients and believe that there's a better way. And I think that's where this is going to come from," he said. "I think the solutions are going to come from us."