Ryan Scully wanted to be a doctor from the moment he began volunteering as a paramedic and firefighter during his freshman year of college. In medical school at George Washington University, he passed all of his preclinical and clinical requirements, as well as two national licensing exams required of all medical students. Just before graduation in 2012, though, he learned that he had not been accepted into a residency training program necessary for gaining his certification as a practicing physician. He would receive his M.D. degree in May with the rest of his class—but without a hospital training spot, he could not practice medicine.
Last year 1,761 M.D.s shared the same fate. And now the White House wants to set aside even less money for doctor training while reorganizing the nation's insurance market. At a time when the new health-care law is expected to create a demand for more physicians, a proposed $11 billion budget cut over the next 10 years guarantees there will be fewer doctors. This could have a serious effect on the health of the nation.
On-the-job training of doctors is a long and complicated business, and since the introduction of Medicare in 1965 the federal government has assumed some of the cost of graduate medical education, particularly at the country's teaching hospitals. The rationale for funding by Medicare, Medicaid, the Department of Veterans Affairs and others—nearly $12 billion a year—has been that the nation's doctors and medical researchers will contribute to the public good, either by treating patients or contributing to advances in medicine.
But the number of federally supported training positions for doctors hasn't changed since Congress passed the Balanced Budget Act in 1997—even while the demand for physicians has been rising to meet an aging population. And now millions of new patients are set to enter the market. The uninsured can now—in theory—enroll in the newly created health-insurance marketplace, much to the credit of the Affordable Care Act. The Congressional Budget Office has estimated that the exchanges will cover 22 million Americans within the next three years. So the administration plans to slash $11 billion in funding for doctor training while adding 22 million new dependents?
According to a 2010 report from the Association of American Medical Colleges, the U.S. already has 16,000 fewer doctors than needed. The AAMC predicts that the shortfall will quadruple to nearly 63,000 over the next two years, reaching 91,1000 by the end of the decade. By 2020, the U.S. will have 45,000 too few primary care physicians and 46,000 too few specialists.
The shortage will have noticeable consequences. Sick children could wait weeks instead of hours to see a pediatrician. Hip-replacement surgery could have a monthlong waiting list. And elective treatments like cardiovascular procedures could take years to get done. The shortage will ultimately produce more rationed care: longer wait times, delayed procedures and surgeries, less time spent with doctors, and quite possibly, more medical mistakes causing patients harm.
The medical community has tried to respond to the coming crisis, which has been developing for more than a decade. Seventeen new medical schools have started since 2005. First-year medical-student enrollment is projected to reach over 21,000 by 2017, a nearly 30% increase from just 10 years ago. This, the AAMC says, will result in an additional 7,000 graduates each year for the next decade. Yet without similar increases in funding for residency training, more medical students will simply mean more displaced doctors like Dr. Scully, with nowhere to earn their credentials.
Unlike medical students, residents can help meet the demand for care that the new law will create. Residents aren't just fully-trained doctors in the making, but also play an important part in direct care, treating patients from some of our most vulnerable populations, including veterans, minorities and the poor. Moreover, teaching hospitals provide 40% of hospital charity care, although they constitute only 6% of all U.S. hospitals.
Ultimately, training new doctors serves every member of the public, which is why the federal government funds the endeavor. The Obama administration's suggested cuts run counter to the basic principle of the Affordable Care Act: that health care is a universal right, not a luxury for the privileged. Congress will decide in the coming months as it negotiates a budget whether to allow the gutting of such a public service. But someone ought to remind the politicos of a fundamental truth: If we're going to offer medical services to millions more people, we will need doctors to provide them.
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