As the Obama administration and Congress work to reform the nation’s health care system, there is significant focus on reining in costs, expanding access to care and improving the quality of services provided.
However, considerable attention also must be given to our country’s critical shortages in the number of physicians, nurses, dentists and other health professionals, coupled with a lack of racial and ethnic diversity among them. This is aggravated by geographic maldistribution of health personnel and imbalances among the medical specialties.
There is a serious — and growing — shortage of physicians in primary care fields such as family medicine, pediatrics, internal medicine and obstetrics/gynecology. In 2006, the Association of American Medical Colleges warned of a pending shortage of physicians and urged a 30 percent increase in the number of graduates from U.S. medical schools. A deficiency of up to 20,000 physicians by the year 2015 has been predicted by the PricewaterhouseCoopers Health Research Institute.
In nursing, the shortage is severe. The Department of Health and Human Services has predicted that, by 2020, our country will have a deficiency of as many as 1 million nurses.
A shortage of 150,000 pharmacists has been projected also by the PricewaterhouseCoopers institute.
If these health manpower issues are not addressed simultaneously with other needed reforms, we will not achieve the stated goals of expanding access, improving quality and controlling costs. Even more ominous is the fact that these manpower shortages and imbalances are projected to become more critical if not resolved.
Beginning in the 1950s, in response to reports of a pending shortage of physicians, Congress provided funds and incentives to increase the number of health professionals. As a result, from 1956 to 1981 the number of U.S. medical schools increased from 80 to 127, and our annual graduation of physicians doubled, from 8,000 to slightly more than 16,000.
Today, with a growing and increasingly diverse population in the United States, there is a pressing need to resolve these manpower issues. But in contrast to the environment of some 50 years ago, for the past three decades, activities to increase the number of health professionals have not come from our leaders in Washington, D.C. Since 2001, however, in several states, new medical schools have opened, and several more are being planned. Private initiatives in Virginia, Nebraska, Florida and North Carolina have included the development of statewide alliances between academic health centers and colleges with significant enrollments of minority students to increase racial and ethnic diversity of entering students.
Because of the lack of significant federal health professions scholarships (again, in contrast to the period 1950-1975), many talented low-income students are discouraged from applying to health professions’ educational programs. Of those students who do matriculate, many graduate with student loan debts in excess of $150,000. The need to alleviate this large financial burden causes many of the new graduates to choose high-paying clinical specialties rather than careers in primary care, where they are most needed.
If not addressed, these health manpower shortages will frustrate efforts to improve access to health care and to enhance the health status of our citizens, and they will impede the goals of reducing costs and increasing the quality of health services. By imposing health insurance mandates on its employees and citizens, Massachusetts has succeeded in increasing the percentage of its citizens with health insurance to more than 98 percent. However, this has led to delays of up to several weeks in securing appointments with physicians for many in the Bay State. This circumstance has demonstrated that the provision of health insurance is only a half step in the process of providing unimpeded access to health services.
In working to expand the number of health professionals, the nation should ensure that its own young people, including those from groups who are underrepresented in the health professions, have greater opportunities and fewer barriers — financial and otherwise — to becoming health professionals. Health and education leaders in Third World countries have been critical of the wholesale recruitment of new graduates from their health professions’ programs by the United States and other Western countries.
Increased opportunities for our own young citizens to become health professionals also would help to address issues regarding the cultural competence of our doctors and nurses. Because of changing demographics, the U.S. Census estimates that by the year 2040, there will no longer be a white majority population in the United States.
Efforts to strengthen the public health systems in our 50 states were cited as an urgent need in a recent report from the Institute of Medicine, titled “HHS in the 21st Century: Charting a New Course for a Healthier America.— Our ability to respond to pandemics, to issues of food safety, environmental health and other national emergencies depends upon maintaining a viable network of state public health agencies.
Another overarching challenge to improving our health care system, reducing waste and the overutilization of services, requires that the nation’s malpractice crisis be addressed. Too often, health professionals, hospitals, clinics and other health organizations practice “defensive medicine— and perform unnecessary tests or procedures in efforts to protect themselves should there be an adverse health outcome.
According to estimates by attorney Philip K. Howard, chairman of Common Good, a legal reform coalition, “defensive medicine— contributes to waste in the health care system upward of $1 trillion per year. This also leads to an adversarial, rather than collaborative, relationship between the patient and the health care provider. Howard advocates for special health courts when there are questions of malpractice. This is intended to deliver fair and reliable decisions and expedited proceedings before a judge who is advised by a neutral expert with explicit standards of care.
Sustained efforts are needed to improve the health behavior of Americans by enhancing the health literacy of our population. Our citizens must be empowered to take responsibility for participating in the management of their own health care, including health promotion and disease prevention activities.
This will contribute to extending the lifespan of our population and will increase their years of healthy life. One such effort includes the development of a National Health Museum in Atlanta, which will have health education programs online and interactive exhibits on human biology and medicine, designed to empower individuals and their families.
In sum, successful reform of our health system will not be the result of one or two silver bullets but rather a coordinated array of silver buckshot on many fronts, over a sustained period, to change the health habits and improve the health lifestyles of all Americans.
Dr. Louis W. Sullivan, a former secretary of the Department of Health and Human Services, is chairman of the National Health Museum, chairman of the Sullivan Alliance to Transform America’s Health Professions and president emeritus of the Morehouse School of Medicine.