What Health Reform Missed: The Doctor Shortage

Health reform seeks to provide coverage for all Americans, adding to the system an estimated 30 million to 47 million, depending on how they are counted, who don’t have coverage today.

The demand side of the reform advocates' story goes like this: Health reform  will pay for itself because of a new mandate penalty slapped on those who refuse coverage. That will ensure a massive influx of new insurance entrants, including healthy strapping young people who don't have coverage today, which means more revenue for the insurance industry. (And more tax revenue because of new taxes, including a tax on medical device makers and an increase in Medicare payroll taxes on the upper bracket, but that's for another day).

But D.C. policymakers have missed one key and crucial point in their narrative. The United States is facing a growing shortage of doctors, say two of the country's biggest doctor groups, the American College of Physicians and the Association of American Medical Colleges. And the missing doctor-shortage supply side of DC’s argument is worse than realized.

Because of this looming doctor shortage, health reform essentially will create market forces that will enact rationing of care, as more insured individuals flood into a system that sees a dwindling number of doctors to care for them. Picking up where insurers left off when it comes to rationing.

This is rationing by supply constraint, because the government cannot ration by price, try as it might.

And that shortage in supply of doctors becomes even more crucial, as health reform seeks to stop the insurance industry’s insidious practice of knocking out people from coverage if they have pre-existing conditions, which most everyone applauds. The doctor shortage becomes exponentially more serious as 71 million baby boomers approach retirement age, and as the creaky Medicare program faces serious strains to deal with a host of new beneficiaries with chronic diseases and fewer doctors to treat them.

The American College of Physicians [ACP], the nation’s top group of doctors notes that a recent peer-reviewed study estimates that there will be a shortage of 35,000 to 44,000 primary care physicians for adults by 2025. It expects long lines and wait times down the road once reform is enacted.

Notably missing will be doctors in key specialties, in general internal medicine and family medicine — the specialties that provide primary care to most adult and adolescent patients, says ACP.

And ACP says in a statement that’s “even before the increased demand for health care services that will result from near universal coverage is taken into account.” Primary care physicians number about 352,900 in the U.S.

Already, the Association of American Medical Colleges says the country could face a shortage of as many as 150,000 doctors by 2025. The number of U.S. doctors now totals around 954,000.The Association says about 45,000 more primary care doctors, who will face the brunt of the new health reform law, will be needed by 2020. It also projects a shortage of 33,100 doctors in specialties such as cardiology, oncology and emergency medicine by 2015.

Meanwhile, medical universities have seen a decline in the number of med school students signing up for family medicine courses, dropping more than 25% between 2002 and 2007, the Association says. Medicare pays about $9.1 billion annually to teaching hospitals in order to maintain residency programs and treatment of Medicare patients, but medical schools fear those subsidies could get cut back.

ACP says when it comes to doctor shortages, Massachusetts' attempt at a universal care model provides a case study of what can happen. There, “shortages of primary care physicians have led to long waits for appointments,” ACP says.

Moreover, ACP says “the demand for primary care in the United States is expected to grow at a rapid rate while the nation’s supply of primary care physicians for adults is dwindling and interest by U.S. medical school graduates in pursuing careers in primary care specialties is steadily declining.”

ACP says the shortage of primary care doctors presents a crisis situation. Primary care doctors provide more than half of “all ambulatory care visits, 80% of patient visits for hypertension, and 69% of visits for both chronic obstructive pulmonary disease and diabetes,” ACP says, “yet they comprise only one-third of the U.S. physician workforce.” It adds: “If current trends continue, fewer than one out of five physicians will be in an adult primary care specialty.”

ACP cites a way out. It says: a "new report by the Council on Graduate Medical Education recommends that compensation to primary care physicians be increased to 70 percent of the average payment for other physician specialties in order to train and retain a sufficient supply of primary care physicians." Question is, will that work? And will it be enough?