From the Editor
Jul 2015

Learning How Health Care Works

Amanda S. Xi, MD
AMA J Ethics. 2015;17(7):599-600. doi: 10.1001/journalofethics.2015.17.7.fred1-1507.


When President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) on March 23, 2010, I was a senior in college working on my engineering design project. Our device aimed to address the $300 million annual cost associated with bleeding complications following cardiac catheterizations. This project was my first glimpse into the world of clinical medicine and its inefficiencies. Questions started to form in my mind about health care policy, but my efforts to understand the subject were thwarted by the seemingly foreign language it was written in. I postponed the effort, reasoning that medical school would be the optimal time to learn the subject.

By the end of my second year of medical school, I was prepared to tackle the first step of my licensing examination but still felt lost in the realm of how health care worked. What did the different insurance plans mean? Who financed health care? Why did cost for the same service or lab test vary so greatly from place to place? How would the ACA affect my patients? My clinical practice? During my clinical clerkships, I listened to heated debates between proponents and opponents of health care reform. I met patients who were getting a health maintenance exam for the first time in a decade after obtaining insurance from the marketplace. More than ever, I wanted to understand the basics of our immensely complex health care system so I could have a meaningful discussion with my colleagues and assist my future patients in achieving their goals of care.

This desire was my inspiration for the July 2015 theme issue of the AMA Journal of Ethics on patient care in the Affordable Care Act era.

Medical school is designed to provide foundational knowledge in basic science and clinical medicine to prepare graduates to care for patients in a formal, supervised residency training program. However, rising health care costs in the US have shifted the attention of medical educators from asking, “What is the best test or treatment?” to “What value does this treatment have, all things considered?” And the things that are considered include the relative benefit of one treatment over another or over no treatment, discomfort and inconvenience of receiving the treatment, and cost of the treatment. Many of us enter medicine to learn the art of healing, not to become economists or policymakers; however, the changing landscape of health care requires current and future clinicians to be cognizant of the numerous components that constitute benefit to a patient.

While crafting this theme issue, I spent countless hours hunched over my laptop trying to understand the various provisions of the ACA and identify ethical dilemmas and important topics of discussion. Questions that arose in my search evolved into the theme issue’s ethics cases: How should clinicians and patients use physician quality metrics in referral and physician selection? What is the role of clinical judgment in applying evidence-based screening guidelines? Should patient satisfaction scores be tied to financial incentives? My research led me to understand why entire degrees are devoted to public policy and economics. I harnessed the wealth of knowledge in these fields by asking researchers to contribute their expertise in areas such as the current status of health care in Massachusetts, primary care incentives, the so-called “Cadillac” tax, comparative effectiveness research, and public and private insurance coverage. With time, and a careful reading of contributions to this theme issue, I started to gain a basic understanding of the ACA’s various provisions and their ethical implications and to appreciate how useful this knowledge has been, and will be, to my clinical practice.

This issue of the AMA Journal of Ethics is meant to increase readers’ familiarity with some of the ACA’s instituted programs and to serve as a springboard for discussion of the law’s effects and merits. Ultimately, I hope that the ethics cases and commentaries will inspire dialogue among students, residents, and physicians about the impact of health policy on patient care.



AMA J Ethics. 2015;17(7):599-600.




I would like to thank Dr. Ernest Krug for his relentless support and mentorship. I would also like to thank the AMA Journal of Ethics team for their suggestions and assistance in crafting this theme issue. Finally, thank you to all of the authors who contributed insightful manuscripts.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.