Public Health Coverage Won’t Save Us—Address the Physician Shortage

For the last four months the news cycle has been buzzing about increases in healthcare.gov enrollment, Medicaid disenrollment eclipsing 20 million Americans, and a renewed click bait “fight” for Medicaid expansion.

What do all of these articles have in common? They all end up corralling reform discussions to narrow legislative proposals which fail to address the underlying issues within our healthcare system: increasing costs and reduced physical access to care. America can’t afford to circumscribe its efforts to just coverage. We don’t have a coverage shortage; we have a shortage of health providers competing over quality care at an affordable price.

There’s been a misleading rhetoric festering within the American healthcare psyche that “coverage equals care.” Why is this notion problematic? Believing coverage equals care prompts voters to demand their legislators focus on reforms that reduce a patients’ cost sharing instead of developing solutions that would upend the synthetic inflation of healthcare prices and gaps in access.

Prioritizing coverage as a sole solution siphons attention from the other issues diminishing healthcare access and health outcomes: speed of service, quality of care, and, most importantly, geographical access. These key factors define an American’s experience with the healthcare system.

Think of it this way, insurance cards do not stitch lacerations. They don’t deliver your child. They won’t replace your grandmother’s hip. Nor will they write your prescription for Remicaid infusions. Only healthcare professionals, not insurance, can provide Americans with the healthcare services and medications they need. Unfortunately, this country doesn’t have enough doctors to keep up with patient demand or compete over pricing.

For example, look at Texas. 127 counties do not even have an OB/GYN, 77 counties don’t have a hospital, 248 out of 254 of Texas’ counties have been designated as primary care shortage areas. 29 percent of Texas doctors are currently at retirement age and 51 percent of Texas medical students end up leaving the state to finish their training elsewhere. These trends combined have led the Texas Health and Human Services Commission to project the state will be short 10,330 doctors by 2032. And it’s not just Texas suffering the consequences of physician shortages—the nation is projected to be short 124,000 doctors by 2034.

Why is upending physician shortages so important? When communities don’t have an ample supply of doctors, patients have to wait to access preventative services and are at risk of forming expensive conditions; then end up paying an arm and a leg in catastrophic intensive unit care or emergency room visits.

Additionally, having a small number of doctors means that there is less competition to bring down healthcare prices for the insured and uninsured. Right now 7 out of 10 doctors are employed by hospitals, insurance companies and private equity. The fact that a majority of doctors are employed at a handful of corporate entities means there are fewer independent providers in the market to compete and undercut inflated healthcare prices.

Look at cash prices for colonoscopies: Advanced Colorectal Care, an independent practice in Nashville, will charge you around $543, all fees included, while a few miles away, Vanderbilt University Medical Center will charge you $4,623 for the same service. All the while the average negotiated rate secured by the largest insurers in Nashville is running around $2,396, an amount you won’t pay in your deductible but will feel later in premium increases the following year.

Simply put, having less doctors working under a handful of employers means a reduction, not only in general competition, but in competition among differing healthcare delivery models fighting to deliver quality care at reasonable prices. Sadly, in this doctor short status quo market, it’s not unusual to see recurring studies concluding that healthcare quality does not scale with higher healthcare prices.

To curb nonsensical healthcare pricing and see the resurgence of independent practice, America needs more doctors: otherwise, patients will have worse health and financial outcomes in the micro and be stuck with skyrocketing healthcare out-of-pocket costs in the macro.

So, what can state legislators do to end the shortages? Luckily, there is a wave of new state policies putting a dent in shortages. Tennessee, Florida, Idaho, Wisconsin, Virginia, Colorado, Massachusetts, and Illinois have passed or are currently working on legislation that creates alternative licensing pathways for highly-skilled foreign-licensed doctors so that they don’t needlessly compete with American medical graduates for residency programs or waste time repeating the three to eight years of general medical education they mastered elsewhere.

Hospitals, ambulatory surgery centers, urgent cares, and even private practices are all looking for physicians right now. And believe it or not, there is a major incentive among foreign trained physicians to come to the states to practice: America is still regarded as the most medically prestigious country in the world, European doctor salaries are often half of what a doctor can make in America, and many legal migrants with medical training that find themselves in America want to make sure their training isn’t wasted doing a profession outside of medicine.

Why should states lead and focus on creating alternative licensing pathways for foreign-trained physicians? Many recent and current federal proposals revolve around giving hospitals additional taxpayer dollars to create more hospital residency programs and revise medical school admission. Some of these proposals have value and should be waded through, but any significant growth in the physician supply would take nearly 15 to 20 years to become apparent. States don’t have to wait on Washington DC, and, due to states’ unique licensing authority, they can act now and roll out the red carpet for top tier medical talent from across the globe.

There is no dispute that health financing is a critical piece in the overall healthcare access equation. But what’s the point of expanding public healthcare coverage if there are still no doctors within 80 miles of a person’s home, or if you get waitlisted with a primary care provider for two months? What’s the point of expanding Medicaid if it only assures an enrollee can wait 4 hours in the emergency room? Our thinking of improving the healthcare system needs to address multiple fronts at the same time; not just rehashing policies that have recklessly financed our current broken system.

Fixing access in our healthcare system requires a holistic approach which cannot afford to be confined to just expanding coverage. There is seldom a silver bullet in reforming public policy, but focusing on ending physician shortages is an action that stands to simultaneously improve physical healthcare access and reduce healthcare price.