Tough call, its very hard to predict where things will stand when you complete your training. Even without the ACA, reimbursements for certain procedures/specialties are subject to change (eg. get cut), cards/GI/rads/rad-onc all have taken big CMS cuts recently, other specialties have taken similar hits in the past, who knows who is next...one could argue that you should avoid fields/specialties where you can be replaced by a mid-level (PA/NP/CRNA) but its impossible to predict to what extent this will actually happen. On the other hand, if you are skilled/hardworking/lucky etc, you could possibly find yourself in one of these fields in a setting where you do not accept insurance, but again this is impossible to count on. There are many factors at play here and it's impossible to know what changes will occur and how quickly they will occur but the overall trend (as it has been the past 20-30 years or so) is that payors (medicare/private insurance companies/hospitals etc) will continue to try and pay you as little as they can for your services. In terms of making a decision, I would start by ruling out fields that you simply could not see yourself doing (eg. if you hate the OR rule out surgery/subspecialties). Amount/type of patient contact and length of training are some other factors to consider. Sorry I could not be more helpful. Best of luck with making your decision.