Argument for...
Presented by Naomi Odell
Each of the AAMC's points reflects the significant impact that the United States health care system will experience in the next 15 to 20 years. As a result, health care reform occupies a prominent spot on the platforms of the current presidential candidates. There are three major concerns, among many, that stand out. First, health disparities among racial and ethnic groups as well as socioeconomic groups are rapidly growing rather than shrinking as many had hoped. Second, the incredibly poor access to health care extends beyond just the uninsured, but also to the poor, rural, or immigrant populations who already face significant challenges. Third, the population of “baby-boomers” born in the late 1940’s and early 1950’s will soon be coming to retirement age, thus presenting a significant burden on the health system.
Some may argue that, in the future, the health care system will be more efficient for serving all populations, therefore requiring fewer physicians rather than more. In the face of the gross disparities in health care currently seen in the U.S., however, it would be a modest estimate to believe that those disparities could be overcome simply by improving the efficiency of the system rather than expanding the physician workforce.
Furthermore, moving towards lower health care costs and greater efficiency is an elusive one at best. Drew Altman and Larry Levitt illustrated the trends in health care costs (which closely follow efficiency) in their telling chart1, the final analysis of which said, “that no approach our nation has tried, over the past thirty-five years, to control health costs has had a lasting impact.” Not to be pessimistic but the health care system, and even improved medical technology, has a long way to go in the next 35 years before it can create the efficiency required to keep stable or even cut the physician work force.
The situation is more complex for baby-boomers. Even with enhanced efficiency in medical technologies and systems, these improvements are limited for the elderly patients. Research has shown that the greatest amount of money and medical attention is spent in the last 5 years of life. This large demand cannot be completely met by ancillary medical staff. The medical needs of the elderly are rarely simple, and an expanded physician work force has the potential to meet this growing need.
In conclusion, the decision to expand the physician work force is wise. Additionally, the mechanism of expansion has been designed for appropriate flexibility, allowing for several “valves” to slow the supply of new physicians if needed. With the growing health needs of the U.S. population, coupled with the distinct national reluctance to support more “efficient” preventative and other medical endeavors, an expansion in the physician work force is apposite.
REFERENCES
1Altman, Drew and Levitt, Larry. 2002. “The Sad History of Health Care Cost Containment as Told in One Chart.” Health Affairs, Web Exclusive.
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Argument against...
Presented by Kevin Christensen
At first glance the AAMC's proposal may seem reasonable because there is a shortage of physicians in many specialties across the country, especially in primary care. However, this shortage is a symptom of a deeper problem with our healthcare system that the “quick fix” solution of expanding medical school enrollment will not solve. In fact, it may even make it worse.
The medical education system and physician payment system in this country discourage students from entering primary care. Two important ways the medical education system does this is by 1) the rapidly rising cost of medical school (with average student debt exceeding $120,0001) and 2) the long length of training required (4 years of medical school and 3 + years of post graduate training). These facts, combined with the comparatively low salary of primary care fields causes students to choose other more lucrative fields2.
Therefore, increasing medical school programs will not fix the primary care shortage. Instead, more students will enter subspecialty areas that pay more and that may or may not already be saturated with physicians. The problem is that the physician compensation model in this country allows physicians to be market makers. Physicians can induce demand for their services and they have incentive to do so in the fee-for-service system. Hence, simply increasing medical school enrollment can actually hurt the American heath care system by increasing the number of highly skilled and highly paid specialists with the ability to create demand for their services. This will increase unnecessary spending and inflate America’s already enormous health care bill3.
Research done by John Wennberg at Dartmouth suggests that this in fact has already occurred. According to his data, if this country practiced as efficiently as the Mayo Clinic, there would be a surplus of 47,000 physicians by the end of 20174.
The real solution to the perceived physician shortage is to eliminate unnecessary spending and increase the efficiency and value of the healthcare system.
REFERENCES
1 New York Times Online
2 New York Times Online
3 Supply-Sensitive Care Dartmouth Atlas Project
4 Christensen, TPS interview, 2007
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