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Universal health care has been a hot topic in this year’s presidential campaign. Whether you are for and against the idea of providing (or mandating) health care coverage for every American, let’s assume that it could become a reality and play out the consequences. Would it improve the quality of care for every American? How has it impacted states which have enacted such legislation?

In April 2006, Massachusetts became the first state in the country to pass legislation for universal health care. In addition to covering more of the uninsured, businesses are required to provide care to their employees, along with an individual mandate for those who can afford health insurance to purchase it. As a result, the percentage of uninsured dropped from 13% in 2006 to 7% the following year but did not eliminate the uninsured population. However, with the same number of providers and an increased insured patient population, the wait times for new primary care visits ballooned to between four and ten months. One contributing factor is that there is one primary care provider for every three specialists in the state. The supply of providers did not increase, only the demand for their services.  In response to this, in March 2008, legislation was introduced in the state to increase the primary care workforce. Only time will tell how effective this will be.

While other nations have made active efforts to build a primary care infrastructure, lifestyle and economic forces in the United States have dissuaded medical school graduates from selecting these specialties. No matter how noble one’s desire to enter medicine, the weight of massive debt can be overwhelming. Why choose general practice when there is another specialty that will pay you twice as much to work the same amount? As a result of these economic forces, many new physicians choose non-primary care specialties in urban areas, leading to an unequal dispersion of providers. The fall-out is that there are currently rural counties in the U.S. with zero physicians.
 
Rome wasn’t built in a day and neither will a new physician workforce. In fact, efforts to increase and direct its numbers will take close to a decade to see any results. This is because the process of influencing specialty selection begins early in medical school. Even if we were able to get 100% of all incoming medical students to commit to a primary care specialty, they would not be eligible to start seeing patients for at least seven years.

Where does emergency medicine fit in to this? ACEP Workforce studies in 1997 and 1999 demonstrated no change in the workforce of approximately 32,000 emergency physicians. Data for a third study is currently being reviewed to see if the workforce has kept up with the significant increase in patient volume nationwide.

What if we need to increase the overall numbers of physicians in the U.S., as many studies have suggested? Over the past quarter-century, we’ve turned to foreign doctors to fill the gaps, particularly in the primary care sector. While the U.S. has benefited from this in the short term, future market forces, including a weakening U.S. dollar, may pull these individuals back to their native countries. In the meantime, their native countries suffer as the drain of these resources depletes their respective health care capabilities. Using this workforce as part of a long-term solution makes us dependent upon others to provide the people and training. For better sustainable solutions, we must look within our own borders.

To address this, the Association of American Medical Colleges (AAMC) called for a 30% increase in medical school enrollment by 2015. In their 2006 position statement, the AAMC offered support to medical schools to help them increase their enrollment, but did not offer specifics as to how this could be accomplished. Only time will tell if this is a sufficient response, as the AAMC does not have a great record predicting physician workforce needs.

In addition to increasing the number of medical students, the number of residency slots must increase as well. Unfortunately, the Balanced Budget Act of 1997 has kept fixed the number of allopathic and osteopathic residents for the past decade.  Because of this, the workforce not only needs to increase to meet future demand but catch up for the past decade.

In the meantime, Baby Boomers are quickly entering the ages where health care consumption will increase. By 2030, the number of adults over the age of 65 will double to more than 70 million. With delays to receive longitudinal care, these patients will receive needed treatment later and present sicker and in greater numbers to our EDs. Not only will we be seeing more patients, but we will have more high acuity patients requiring admission, leading to increasing boarding times and periods of ambulance diversion.

How do we get Washington to accept this fact and move towards much needed reforms? Last May, SAEM invited the health care advisors for the presidential candidates to a town hall meeting. Upon questioning it became clear that they were unaware that a shortage of physicians was a major issue. “Train more doctors” isn’t as catchy a sound bite as “health care for all.” The proposed plans of both presidential candidates have promised to increase the number of insured in some fashion, increasing the amount of money in the health care system. The trade-off is likely to be increased physician accountability in terms of how this money is spent. To mitigate the increased costs, this is going to lead to an increased burden of reporting by providers to prove that quality, cost-effective care is being delivered in order to be reimbursed.

It is the responsibility of every emergency physician to review the platforms of the two candidates before voting. Will the candidate mandate health care coverage? If so, what provisions will be made to bolster the physician workforce? These details will likely have a significant impact on how we practice medicine over the next four years. The challenge is to look beneath the rhetoric to see what truly lies in store for the future of health care and the patients we serve.
 

Comments   

# Gibson GH ER Medical DirectorThomas H Nelson, MD 2008-10-03 18:06
In my small community hospital ER, we have already become too busy. This is going to be hard.
Reply
# MDilene brenner 2008-10-04 16:07
Fascinating account of the law of unintended consequences. In retrospect, it should be obvious that more insured = more demand for preventative primary care = increased wait times in offices = increased visits to the ER

It is a good lesson: if obama wins and implements his (mostly) universal health care plan, and it works to some degree, the country as a whole will experience the same problem of decreased primary care coverage.

Also, what of the supply/demand/p rice curve? If there is decreased supply of doctors vs. increased demand, that will put extreme pressure on prices. This could cause and upward spiral in health care costs.

the answer, is increased supply. And the only way to get that is to make it more palatable to be a PMD: eliminating debt for PMDs could go a long way to do that. And we as a country need to address the issues that PMDs face every day that make practicing so painful, such as regulations, paperwork, pre-approvals/d enials, rejections of payment for services rendered, malpractice risk...and so on.

Thanks for the article.
Reply
# MDAlan Kenwood 2008-10-04 17:35
Creating more administrative regulation is not the best way to dealing with the inequities in the primary care specialties. The biggest step we could take as a nation in dealing with this problem would be to make medical school education FREE. Then, debt would no longer be a driving force in choosing one's specialty. Of course, this would not eliminate the need for other reforms in payment to physicians.
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# MDJohn Janousek 2008-10-17 15:53
Obviously there has not been a comprehensive review of the present and future state of healthcare and physician workforce on both the state and national level, and I do not see the current presidential candidates doing so either. We can only hope that our medical societies get their say at some time and it is taken to heart. We will continue to see foreign medical graduates filling primary care residency slots and filling the need for US primary care physicians. Emergency Departaments and Urgent Care Centers will become busier, and will need to see more and more patients in less time to remain financially viable. The federal government should reimburse Primary Care better through Medicare payments, give reimbursement or bonuses to medical students who choose primary care,and subsidize residency training for any physician who has been practicing in another specialty who would like to switch to primary care. Canada had a problem getting physicians in their military so they offered a 225k bonus-guess what happened-it worked!
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# Jon 2008-10-29 13:53
Universal Health Care coverage in Massachusetts does not affect the number of primary care physicans. Here in KS we have a primary care physician shortage, particularly in rural areas, and do not have universal health care. If Obama is elected, his changes will make a difference and improve health care coverage.
Reply
# Dan Handel 2008-10-31 02:32
Jon,
In hearing Obama's statements and listening to his health policy advisors at SAEM last May, they are unaware that there is a workforce issue. The latter simply doesn't have the same media appeal as the coverage issue. While I am all for universal healthcare, it does not create more providers, especially primary care ones. Massachusetts has one of the highest concentrations of MDs in the country, and they still can't get all of their citizens seen in a timely fashion. Only time will tell, but I anticipate Obama's plan will simply spread the Masssachusetts situation throughout the country.
Reply

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