Health-care Reform Is Welcome But Falls Short in Training Providers

At long last, the United States has taken a monumental step toward catching up with the rest of the civilized world in providing affordable health care to nearly all its citizens.

When its major provisions take effect in 2014, the health-care legislation that Congress exacted last month will extend coverage to 32 million Americans who are presently uninsured and millions more whose coverage is deficient.

Yet, while generating a huge increase in the effective demand for medical services, the legislation does next to nothing to meet the nation's need for more doctors to supply them.

Unless the impending shortage of physicians is redressed, it could well make a mockery of the legislation's claim to make health care more accessible as well as more affordable.

To paraphrase an old saying about justice, care delayed can be care denied. And there promise to be plenty of delays in getting to see doctors and even refusals on the part of many to accept more patients for whom government-set reimbursement rates are well below those of the privately insured, namely seniors covered by Medicare and the poor covered by Medicaid.

Unless there's a big increase in the nation's ranks of newly-minted doctors, the Association of American Medical Colleges projects a shortage of some 50,000 physicians by 2015, rising to 100,000 by 2020 as an ever growing number of aging baby boomers need more medical attention. About half that shortfall is in primary care physicians who represent the frontline of care providers and are already believed to be in short supply, especially in rural areas.

To help close the gap, the AAMC has called for a 30 percent increase in U.S. medical school enrollment to about 22,000 admissions annually. But this number has only been growing by a few hundred slots per year, and impending higher education funding cuts in most states could put a halt to further growth or even lead to cuts.

The biggest impediment to increasing the supply of doctors, though, is a statutory cap on the number of residents coming out of medical schools whose further training is largely federally funded. This cap was set at about 25,000 new slots per year by the Balanced Budget Act of 1997 and remains unchanged. Efforts to get a 15 percent increase included in this year's health-care legislation were unavailing.

One can debate whether the federal government ought to be almost the sole source of graduate medical education funding in this country, but that's the way it is as matters stand. Because residencies average about four years, Medicare is currently paying $9 billion a year to support around 100,000 residents in teaching hospitals across the land, funding that covers both their stipends and the institutional costs of the hospitals that oversee them.

In addition to M.D.'s coming out of the nation's 130 medical colleges, the residency ranks also include about 2,500 doctors of osteopathy graduating each year from about 30 D.O. colleges and by what are known as IMGO. That stands for International Medical Graduates, and while foreign-trained doctors are viewed with disdain by some, they now account for close to 25 percent of the nation's 730,000 practicing physicians.

Bills providing for a 15 percent increase in the residency cap were supported by the AAMC, the American Medical Association, the American Hospital Association and many other health-care organizations. And the bills stipulate that at least 25 percent of the increase would have to go for primary care doctors, the sector where shortages promise to be most acute. The $1.35 billion annual price tag on the increase is small in relation to the trillion-dollar cost (over a decade) of the sweeping legislation as a whole, let alone the insidious cost of its failing to deliver on its promise of accessible care for all.

Failure to include it remains a source of perplexity and consternation to many in the graduate medical education field. "It's really shortsighted, like telling us to drive a car with no gas," says Eugene Mangiante, executive associate dean of the University of Tennessee Office of Graduate Medical Education in Memphis.

In an appeal that went unheeded prior to passage of the legislation, the AAMC's president, Darrell Kirch, cautioned that, "Because it takes so long to train a new physician, Congress must lift the freeze on support for medical training now, as part of health-care reform. While the cost to all new physicians is significant, it is less than 1 percent of current Medicare expenditures and an essential investment if people are to have timely access to a physician's care... Congress is right to expand insurance to as many Americans as possible. But it also has a responsibility to ensure that the nation is cared for by more than an insurance card and an answering machine."

A blog touting the health-care legislation's benefits that was posted after its enactment by the White House's director of health care reform, Nancy-Ann DeParle, includes a claim that, "Going forward we will provide $1.5 billion in funding to support the next generation of doctors, nurses and other primary care practitioners." However, my repeated attempts to contact DeParle to clarify this claim were unavailing, and no one in the White House media relations office could explain what it meant.