Here’s one we can solve
July 29, 2012 — The causes of — and solutions for — many of the problems plaguing the U.S. health care system continue to generate intense disagreement. The severe shortage of doctors, however, should not be thought of as one of those problems, though you would never know it from reading “Doctor Shortage Likely to Worsen With Health Law,” the lead story in Sunday’s New York Times.
The casual reader of the Times’ piece would be forgiven for thinking that the shortage — projected by the Association of American Medical Colleges to exceed 125,000 by 2025 — is one of those intractable issues that defy well-intentioned policy makers. The article devotes only a single paragraph to explaining the root causes of the shortage, with no mention of how policy makers have, at best, failed to address those causes and, at worst, seriously exacerbated them:
Medical school enrollment is increasing, but not as fast as the population. The number of training positions for medical school graduates is lagging. Younger doctors are on average working fewer hours than their predecessors. And about a third of the country’s doctors are 55 or older, and nearing retirement.
Yes, all of that is true, but as Remapping Debate has reported, the response is squarely within the realm of public policy. What’s more, these are not newly discovered problems, and there have been numerous opportunities to address them over the last 20 years. But through a combination of resistance and apathy, policy makers have failed to make use of those opportunities time and time again.
Some context would have been helpful: in the early 1980s, most leading experts inside and outside of government were actually predicting that there would be a surplus of physicians by the year 2000. In response to those predictions, lawmakers decreased the amount of available funds for medical school construction and capped the number of slots available for residency training. Then, in the late 1990s, the surplus-consensus came apart, and by the early 2000s, a new consensus had formed around the certainty of a shortage. Despite clear evidence and broad agreement among most experts, policy makers failed to reverse their previous actions.
Insufficient medical school enrollment is the most basic and pressing problem, and, as the article reports, there have been some modest efforts to open new medical schools and to increase enrollment at existing schools. But the construction of new facilities has traditionally been financed, in part, by state governments, most of which have actually been cutting funding to their higher education systems.
Moroever, in the past, the federal government provided crucial assistance. In the 1960s and 1970s, for example, enrollment at U.S. medical schools more than doubled, largely due to funding from the 1963 Health Professions Education Assistance Act, which provided grants for the construction of new facilities and the expansion of existing schools. Another version of that Act is clearly needed, but champions in Congress have not emerged.
And even if medical school enrollment were to increase dramatically, the number of practicing physicians would not, because of a 1997 law that capped the number of medical residents at about 100,000. Without lifting that cap, the overall number of doctors cannot increase. Lawmakers have had plenty of opportunities to do so: in 2009, legislation was introduced in both the House and the Senate that would have increased the number of residency slots by 15 percent, targeting the increase to residencies in primary care. That bill died a silent death, but was resurrected as an amendment to the Affordable Care Act (ACA). But due to infighting among legislators and interest groups, the amendment was not included in the final version of the ACA.
You would never know any of that from the Times article, though. Nor would you know that there is serious resistance to increasing the number of physicians among lawmakers of both parties. This resistance has its roots in the broad unwillingness to recognize that providing adequate healthcare for a growing and older population will be an expensive proposition.
Instead, the reporters rely on a flimsy and misleading hook: that the ACA will increase the need for medical services beyond what the system can provide. What has changed, obviously, is not the need for services but the access to them. And what that means is that lawmakers have been asleep at the wheel for not only a couple of years, but for decades.
What we’re left with is the idea that “changing how doctors provided care would be more important than minting new doctors.” Some changes do have to be made — including creating a structure where doctors are not forced to rush through an over-booked schedule. But it doesn’t help if we don’t acknowledge that the underlying doctor shortage is a medical emergency that would be well on the way to be resolved were policy makers prepared to act.