The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act created Medicare in 1965. It assures that 32 million Americans will gain access to health insurance for the first time. But who will care for these people?
The flood of newly insured people will create a surge in demand for physician services. By 2015—one year after the major provisions of the ACA take effect—the US will have 63,000 fewer physicians than it needs to meet this demand, according to the Association of American Medical Colleges.
The shortfall will hurt everyone, but its impact will be devastating for medically underserved populations where finding a doctor is already difficult. This includes nearly 20% of the US population.
Unfortunately, the ACA doesn’t include a manpower plan that sufficiently accommodates the surge. The most optimistic projections suggest it will add 500 or so physicians per year to the workforce during the next decade, and even that modest growth has recently come under attack by House Republicans.
Two weeks ago, the GOP-controlled House voted 234 to 185 to eliminate $230 million in mandatory ACA funding for the creation of a new teaching model for residents in primary care. The model is based around “teaching health centers,” which would be placed in medically underserved areas and mirror the practice environment residents will enter upon completion of their training.
The GOP isn’t against the new training model, but objects to the automatic, mandatory payouts associated with it. They propose that funding for the manpower initiative should be subjected to votes each year during Congress’ annual appropriations process. “It’s time to move these programs back to the discretion of this Congress,” Marsha Blackburn (R-Tenn.) explained, referring to it as one of many “slush funds” provided by a debt-ridden federal government.
Democrats counter that subjecting the funds to an annual, politically-charged appropriations process will dissuade physicians from entering primary care. “Training physicians should be assured with funding they can rely on,” said Rep. Henry Waxman (D-Calif.).
The House bill will likely never see the light of day in the Democratically controlled Senate. But it is distressing that Congress is wrangling over a largely inadequate solution to the coming physician manpower crisis.
What Should Be Done?
The AAMC has asked Congress to require at least a 15% increase in residency training slots beginning immediately. This would add 4,000 physicians per year to the pipeline. To do this, the AAMC suggests that Congress overturn a 1997 law that froze Medicare-funded residency positions, and increase by at least 15% the number of GME positions funded by Medicare.
This isn’t a bad idea, but it seems like a pipe dream with public opinion entrenched against new spending programs and Congress posturing for the press around various budget deficit plans.
The only viable alternative was proposed by the Institute of Medicine last fall. The IOM concluded that the best way to deal with the coming tidal wave is to expand the roles and responsibilities of nurses.
Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended incentive programs that increase the number of nurses with bachelor degrees to 80% by 2019. It further recommended that nurses assume central roles in redesigned, team-based care systems, and that regulatory and institutional obstacles, including limits on nurses’ scope of practice, be removed so that advanced practice registered nurses can practice more freely. This includes increasing their power to prescribe drugs.
The IOM report cited studies of care systems (including the VA) that have already implemented such models. The studies show the new systems to have experienced no fall-off in the quality of care while cutting the annual increase in health expenditures by more than 50%.
Although organized medicine has scoffed at the IOM report, I think these changes are inevitable. The ACA is right-minded, socially responsible legislation that can improve access to care for tens of millions of Americans, but it can’t work (especially in an era of unprecedented deficit spending) unless health professionals figure out how to transform our health system so as to better leverage its professional workforce.
A redesigned system that focuses on patients is a lofty, socially responsible goal, the kind that drives people to become health professionals in the first place. Physicians will sit atop these newly redesigned teams and remain responsible for patient care; they needn’t worry about that. But they need to set-aside any unreasonable urges they may have to keep the status quo and let this transformation occur. Otherwise, they are going down with the ship.