Pre-Existing Conditions and the Potential Cost of Repeal and Replace on the Medically Underserved

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Michael Castellarin, MD

In March of 2010, the Affordable Care Act (ACA) became the most significant change to the US healthcare system in almost half a century. This January, health care reform again entered the national conversation as discussions to repeal and replace the ACA ensue. One of the most influential provisions of the ACA was the pre-existing conditions clause which led to a ban on medical underwriting, thus providing health insurance coverage for a multitude of people previously ineligible unless covered by an employer.

As a family medicine intern training at an urban federally qualified health center (FQHC), I care for the medically underserved; a population defined by their complex health care needs and lack of financial resources which, prior to the ACA, left this group particularly vulnerable to medical underwriting. As health care policy shifts once again, the importance of pre-existing condition coverage must be realized and must be protected, particularly for those less fortunate.

Prior to the passage of the ACA, the practice of medical underwriting was commonplace in the individual health insurance market. Common ailments such as diabetes, heart disease, and obesity left patients uninsurable. Those insured through an employer avoided underwriting but oftentimes those in medically underserved populations were forced to shop for health insurance on the individual market because of unemployment or low wage employment without employer-sponsored insurance.

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Feed a Discipline (With Research Questions): Become Shark Bait

Winston R Liaw, MD, MPH

Winston R Liaw, MD, MPH

Research is to see what everybody else has seen and to think what nobody else has thought.

  • Albert Szent-Gyorgyi

Each year, my colleague, Alex Krist, and I sit down with our Virginia Commonwealth University family medicine residents to brainstorm potential research topics for their scholarly activities, and each year, we encounter a similar series of events. Initially, there is silence (frequently prolonged and often deafening) followed by musings about their lack of research experience. Then, a brave soul offers a question that has been plaguing her. A classmate asks a similar but related question. The conversation reminds a third resident about a different question he always wanted to answer. By the end of the hour, we have a list of fascinating, important questions.

  • Do calorie counters improve patient outcomes?
  • Why do our patients use the emergency room next door when our walk in clinic is open?
  • Has the new patient portal affected the volume and type of phone calls we receive?
  • Are patients at the community health center interested in doing video visits?

Your STFM Research Committee thought that family medicine residents and faculty nationwide may similarly have pressing questions to answer but lack the means to do so. Initially conceived by STFM Research Committee members Tammy Chang and Rob Post, we launched a session at the 2016 STFM Conference entitled: “Shark Tank for Family Medicine: Real-time Feedback for Primary Care Research Ideas”. During the workshop, seven participants pitched research ideas to three “sharks” (well-established primary care researchers). The sharks provided real-time feedback and then selected participants to mentor over the year. For those of you not tuned in to pop culture, our workshop is based on the TV show Shark Tank where contestants pitch business ideas to established entrepreneurs and winners receive funding and mentorship.

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Medicine Inherently Requires All Physicians to Be Teachers


Throughout my medical education, my best mentors have been family physicians. Without exception, they are enthusiastic, committed, passionate, intelligent, and innovative leaders who have inspired me to be the best family physician I can be. As I cross the midpoint of my residency training, I have spent more time thinking about the next steps in my career and how to best continue to affect change. I want to prioritize teaching family medicine and pursue a career either in academics or in a position where I can work closely with medical students or residents.


Karl Dietrich, MD, MPH

Medicine inherently requires all physicians to be teachers, and find effective and efficient ways to share information with patients. As a high school teacher prior to pursuing medicine, this was one of the appealing parts of becoming a physician. By embracing our role as teachers, we allow our patients to learn about their own health, become their own best advocates, and hopefully influence others to think more about their health. Teaching family medicine appeals to me because it could broaden my potential impact by not only increasing the number of future family physicians but by increasing the number of physicians in other fields with a strong understanding of the value of family medicine. We know that a strong primary care system will be essential to the ongoing success of our health care system, and I see no better way to ensure that than by increasing the number of committed family physicians in this country.

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