It never ceases to amaze me that the leftists in charge are focusing the health care debate on rationing and redistribution. Lost in all of their histrionics about expanding the role of government is a simple fact. In order to provide more health care services to people who don’t currently get them without taking them away from others, it will be necessary to train more people as medical professionals. Obama is trying to pass a bad plan that won’t take effect until 2013. I propose that one key element of any good plan to improve American health care wouldn’t show any results for SEVEN YEARS. Once someone starts medical school it takes at least seven years for them to become a practicing doctor, a time which is long relative to the news cycle and even election cycles. This probably explains the intransigence of politicians in putting forth proposals to correct these impending shortages.
The liberals propose that we need to provide health care for the speciously quoted figure of 47 million uninsured Americans. If you’re suggesting that nearly a 1/6th of the people in this country are not getting any medical care, then in order to change this, it is necessary to increase the production of medical care by about 20%. Of course, many people are only temporarily without insurance, some of them are affluent enough to be self-insured, and they all still can receive treatment when they show up at emergency rooms. This doesn’t change the fact that people with a good insurance plan will get more and better treatment than someone without money or insurance, but the 20% figure is obviously somewhat inflated.
Unlike The Won, I do not expect that very many doctors perform needless surgeries in order to boost their income. On the other hand, I will point out that the American Medical Association is for many purposes, a guild. Their members sit on state licensing boards that have prevented new medical schools from being opened and existing schools from increasing their enrollments for decades. While the desire to maintain high admissions standards in order to mitigate future rates of malpractice is admirable, it has the obvious consequence of constraining the supply of physicians and raising the fees that they can charge. It also shunts aspiring MDs into academically marginal programs in the Caribbean and schools of osteopathy.
Most medical professionals are overworked. How often do you hear of a competent doctor or nurse who can’t find a job? Who has waited in an emergency room or doctor’s office for hours beyond their scheduled appointment time and thought to themselves that there are too many doctors?
The population of the United States in 1980 was 231 million, and today it stands well over 300 million. (The results to be fudged by for ACORN employees in 2010…) From the election of Ronald Reagan until very recently, the number of MDs graduating from U.S. medical schools has stayed fixed at 17,000/year. Despite the failure of about a third of Americans to finish high school, our top students are excellent. I find it hard to believe that we couldn’t admit the same proportion of the population to medical school that we did nearly thirty years ago without endangering patients to an extent greater than we did back then.
Aside from the increase in our population, we have a demographic bubble facing us. Among adults, the older you are, on average, the more medical care you’ll require to stay alive for an additional year. Another point is that doctors have gotten better at performing surgeries in recent decades. Paradoxically, this results in more surgeries because people are more likely to survive only to inevitably develop a new ailment that requires another surgery. Such is the human condition.
You’ll notice that I said that we need more medical professionals. It’s hard to say offhand exactly which subgroups of providers need the greatest increases in their ranks, but this is how the debate needs to be framed. We need to study how we can most cost effectively improve the availability of medical care by increasing the ranks of MD, PA, and nursing school students. Among the things to consider are where to locate new schools and whether it is better to expand existing schools than to open new ones. Another consideration would be to make it easier for people who are not U.S. citizens or permanent residents to attend U.S. medical schools. We take foreign doctors for our residency programs, but we deny the best foreign undergraduates the opportunity to learn in our medical schools. This is foolhardy.
With regards to the training of specialists, we need to take a close look at how many more people we could train to become highly competent neurosurgeons, cardiologists, and radiologists, and how it could be done. There are fundamental limitations on the availability of people to perform the most heroic operations and design the most complex pharmaceutical treatment strategies, and as a result there are also severe limitations on the availability of competent instructors in these specialties. One readily foreseen consequence of any proposal to increase the ranks of practicing physicians is that it will reduce their ability to charge for their services. The standards for gaining entry to top law schools, banks, and medical schools are very similar. People need to have succeeded in challenging academic programs and thus repeatedly shown that they do their work in order to stand a good chance of getting admitted to any of them, and such people are few and far between. They have choices. We must seek to emulate highly trained and successful specialists, not punish their livelihoods.
Any health care reform that requires a uniform fee schedule for services while bringing in new members to the profession who are less capable than the existing ones will have a tendency to dissuade talented people from pursuing a career in medicine. If the availability of residency slots in all specialties were increased in proportion to the increase in MD graduates, I’d expect that most of the added MDs who would not have made the cut for admission to medical school in previous years would become general practitioners and that those who would have otherwise become general practitioners would get admitted to specialties. (The prospect of my family doctor performing brain surgery on me is frightening, but what’s the alternative?) Perhaps one way to mitigate the risks of this expansion in the ranks of doctors would be to make the length of time required to complete medical school and residency more variable so that it would be common for about 20% of the students to spend an extra year in either. Of course, if 20% of residents need to take another year to be trained, then this requires 0.2 additional years of instruction per new doctor during which they need to be overseen by an established doctor, so providing the needed training now cuts into the availability of treatment in the present.
I hope that people have some comments on this. I find it ridiculous that we’re fighting over all these details about how to pay for care when our demographics and collective corpulence are causing our demand for health care to outstrip our capacity to provide it. Proposals to train more medical professionals ought to be the centerpiece of any health care plan. I’m not a doctor or an attorney specialized in the medical licensing process, but it seems that this is a partial solution that can revive federalism through trials in our laboratories of democracy. If state legislators and governors can work to streamline and fund the process for expanding medical enrollment with little to no involvement of the federal government, then perhaps we can build a better health care system despite the best efforts of Congress and Obama to destroy it.