The Affordable Care Act is the most important piece of federal health care legislation since the Social Security Act established the Medicare program 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?
Our health care system had been plagued by a severe and worsening physician shortage even before the new law was passed. In fact, a 2008 study by the Health Resources and Services Administration projected shortages of 35,000 surgeons and 27,000 medical specialists within 10 years, and that’s not even counting expected shortfalls among primary care practitioners like those in Family Practice and Obstetrics.
Those 32 million newly insured people will create an unprecedented surge in demand for physician services, exacerbating this shortfall by at least 50%, according to a new report by the Association of American Medical Colleges.
The report estimates that by 2015—which is one year after the major provisions of the Affordable Care Act take effect—the US will be short a whopping 63,000 physicians—including both PCPs and specialists. Previous analyses had pegged the shortage at 39,600 physicians.
Nearly half the shortfall, 33,100 to be exact, involves specialists like cardiologists, oncologists and emergency medicine experts. For certain specialties like urology and thoracic surgery, the number of physicians is actually projected to decrease.
The report adds that the shortage will only get worse after that. By 2020, our nation will be short by 45,000 primary care physicians, and 46,000 few specialists, the report predicts.
The physician shortfall will be exacerbated by demographic trends in the US. The number of Americans who are at least 65 years old (a group known to require more medical care than younger folks) will increase by 36% during the upcoming decade, according to the Census Bureau. The graying of the US population is also expected to mean that nearly a third of today’s practicing physicians will retire within the next 10 years.
The physician shortfall will hurt everyone, but the AAMC projects that the impact will be particularly severe on medically underserved populations where finding a doctor is already quite difficult. The population in question includes nearly 20% of Americans living in inner-city and rural areas.
Offsetting this trend to some degree is the fact that (provisions in the Affordable Care Act aside) the number of medical school graduates will increase by about 7,000 per year during the next decade. Unfortunately, this increase won’t come close to keeping up with the projected surge in demand for physician services.
What Should We Do?
While team-based approaches like “medical homes” can ameliorate the looming crisis to some degree, few believe they will eliminate it.
Recognizing this, the AAMC recommends that Congress should mandate at least a 15% increase in residency training slots beginning right now. This would add 4,000 physicians per year to the pipeline. This surge is not contemplated by the Affordable Care Act, which in the most optimistic of projections will add approximately 350 physicians per year for the next decade via small primary care grants and the reshuffling of residency programs.
To reach its proposed target of 4,000 new physicians per year, the AAMC is calling on Congress to overturn a 1997 law that froze Medicare-funded residency positions, and increase by at least 15% the number of GME positions funded by Medicare. That seems like a pipe dream with Congress mired in partisan gridlock and public opinion firmly entrenched against new spending programs.
Beyond this, the options are slim and controversial. We either increase the numbers of foreign medical graduates that we allow to practice in the US, or we expand the scope of practice for nurses and other non-physician health professionals (as recommended by the IOM this week), enabling them to help shoulder the burden created by accelerating demand for medical services.
To those who would disagree with these solutions–which can work at least to some extent–I ask, “What alternatives do you propose?”
Glenn Laffel MD, PhD
Senior VP Clinical Affairs
Practice Fusion EMR
