Cincinnatus BLOG *** Political Commentary - Social Commentary

The only thing missing from current Health Care Reform proposals is a plan to actually provide, health care. Insurance schemes both public and private, electronic medical records and legal reforms may make health care more affordable and administratively efficient but they don’t answer the real question; will Americans actually receive better health care, or in many cases any health care at all?

What should be obvious, seems lost in the political rhetoric, we don’t have the physicians, nurses and other health care professionals to actually provide quality universal health care despite the fact that we spend more, per capita on health care than any other country in the world. In the U.S. we spend approximately $6,000 per capita as compared to about $3,500 countries with universal national health care systems such as France and Germany. In fact, we spent $2.2 trillion in 2007 on health care, or 16.2% of our gross domestic product (GDP).

We appear to be poised to add about 46 million uninsured patients to the system over the next few years or a population greater than the size of Spain.  If we make the reasonable assumption that American physicians currently work a full day; who is going to treat this new influx of patients. While it may overstate the case to say that these patients are not receiving any healthcare, it is instructive to calculate how many physicians would be needed to treat 46 million additional patients. In the U.S. we have approximately 3.0 physicians per 1,000 people thus, if we extrapolate we would need an additional 138,000 physicians to treat this population.

We are already behind the curve; there were 15,242 medical school seniors in 2008 to fill approximately 22,000 residencies. Not surprisingly, roughly 4,650 were filled with foreign graduates, some of whom were Americans who had studied abroad. The balance was filled with graduates of osteopathic schools. The medical-colleges association has called for a 30% increase in enrollment by 2015 as compared with 2002 primarily by expanding existing schools and opening new campuses. This goal may be unachievable. Thus, in the future, larger numbers of foreign medical school graduates will be needed to meet our needs since, expansion of medical education Is unlikely keep pace with the increased need for physicians.  For example, the medical-college association estimates that if physician supply and use patterns stay the same, the United States will experience a shortage of 124,000 full-time physicians by 2025.

The question we must answer is - will we continue to get the high quality medical school applicants in a world in which the government will play and increasingly important role either directly though programs such as Medicare and Medicaid or indirectly by setting the standard of reimbursement which is likely to be emulated by private insurance companies? Given the run-away costs in the American health care system there is likely to be significant downward pressure on physician reimbursement. This comes at a time when it costs approximately $200,000 including living expenses to attend medical school in the U.S. A recent study published in the New England Journal of Medicine estimated that 23% of medical school graduates begin there professional life with $200,000 or more of debt from pre-med and medical school loans. In addition, a substantial number have over $100,000 in debt by the time they graduate. At what point is it uneconomical to become a U.S. physician knowing that government is dedicated to reducing its expenses by limiting the income a physician can earn?

Medical students in Europe, where national health programs are virtually universal do not pay to attend medical school, the government who in a very real sense limits the ability of these future doctors to earn a living, has made a implicit bargain with the students; education is free but the government reserves the right to determine your level of compensation throughout your professional career. At the moment, the American medical student is asked to go into hock for $200,000 or more while their ability to control their level of compensation once they graduate may be determined by government bureaucrats.  Americans are likely to perceive such a system a inherently unfair, and may insist that the either the government pay for medical education or refrain from limiting the free market in medical reimbursement.

In 2008 the number of students applying to medical schools dropped by 3% according to the Association of Medical Colleges at a time when American medical schools are being urged to accept more students to counter the projected shortage of physicians.

Given the economic uncertainty that lies ahead for physicians it would not be surprising to see a precipitous drop in high-quality medical school applicants. After all, these bright young men and women can become investment bankers, lawyers, engineers etc. and not be subject to government restrictions on their ability to earn a living.

If we are to continue to attract our best and brightest to medicine a national policy that, is perceived to be fair must be developed.