Dobbs Opened Up an Attack on Doctors

“The whole sorry affair should remind us of one key reason why Roe was decided in the first place: to protect doctors.

It is a sad fact that some doctors will avoid providing essential medical care if the treatment in question is politically controversial. These doctors understandably fear that an overzealous prosecutor might use a vague law against them, just as Indiana’s attorney general threatened to do here.

Doctors who deal in certain types of pharmaceuticals run the same risks. In fact, just three days after Dobbs, the Supreme Court actually enhanced the legal protections for doctors who prescribe opioids. In an ironic twist, the Court did so while effectively reviving a pre-Roe case that protected the medical privacy rights of abortion providers.”

“The Dobbs decision obliterated those medical privacy protections by a narrow 5–4 vote. Yet by a 6–3 vote just three days later, the Supreme Court embraced the logic of Roe’s most important predecessor (Vuitch) when it strengthened the medical privacy rights of doctors who prescribe opioids (Ruan).

This contradictory and confusing state of affairs is bad both for medicine and for the law, and it ought to be fixed as soon as possible. Whenever a poorly drafted statute is open to abuse by an overreaching prosecutor, the Supreme Court has the option of using the void-for-vagueness doctrine to strike down the offending law. The Court could also require that all abortion regulations conform to the doctor-friendly rules spelled out in Ruan and Vuitch. Particularly egregious laws, meanwhile, can be invalided by the courts for lacking a rational basis.

The Constitution provides firm procedural safeguards whenever the government interferes with life, liberty, property, or privacy. The Supreme Court needs to ensure that doctors still enjoy those safeguards’ benefits.”

Why well-qualified medical school graduates can’t get jobs — despite doctor shortages

“despite the great need for more doctors, there are still huge gaps between the number of aspiring physicians and the space available to train them, a dynamic that keeps perfectly well-qualified medical school applicants and graduates out of the pipeline.

In 2021, for instance, there were a record-setting 42,508 active applicants for residency programs — 3,741 more than in 2020 — but only 35,194 first-year positions, according to the National Resident Matching Program. Although the number of residency spots has been creeping upward in recent years, the growth has not been fast enough to close the gap.

At the root of the mismatch between physician supply and demand are decades-old limits on medical school enrollment and outdated rules governing the federal funding for most residency programs. While Congress has taken some baby steps toward increasing that funding, it has yet to make the kinds of bold changes necessary to create a sustainable and pandemic-resilient physician workforce.”

“The US medical system falls behind those of our peer countries in so many ways. We have higher administrative costs and worse outcomes than other high-income countries — and we also have fewer physicians available per person.

“If you take a look at EU countries that have sophisticated medical systems,” explained Janis Orlowski, chief health care officer at the AAMC, “they have between 30 and 40 physicians per 10,000 people. In the United States, we have about 26 to 27.”

It’s not an apples-to-apples comparison, in part because physicians use their time differently in different systems. But it’s clear the shortage is a burden, and it’s likely to get worse as the US population grows larger and older.”

“In a December 2021 survey conducted by the American Medical Association, one in five physicians said they would likely leave their current practice within two years, and about a third said they’d likely reduce their work hours in the next year.

The larger workforce trend has been dubbed the “Great Resignation,” and the reasons doctors are quitting echo the factors contributing to shortfalls among other health professionals, including nurses, medical assistants, physical therapists, and pharmacists. Burnout, fear of exposure, pandemic-related mood changes, and workload were all associated with intent to leave the profession.”

“It’s easy to imagine a simple solution for this problem: Incentivizing doctors from other countries to immigrate to the US. But this is not as quick a fix as it seems. Most states require doctors to complete residency training in the US, which takes at least three years. That applies even for doctors who practiced independently at expert levels in other countries; the chief of surgery at the fanciest hospital in India would still have to repeat residency in order to practice in the US.

About 13,000 of the residency match applicants this year were graduates of international medical schools, 8,000 of whom were not US citizens. But no matter how many additional doctors want to jump through the hoops necessary to practice in the US, long waits for visas and restrictive terms limiting where and for how long they can practice in the US make it unlikely many more will be added to the health care workforce in the near term.”

“One major bottleneck in the physician pipeline is medical school admissions, which are only graduating about 27,000 students each year. “That started in the 1980s with the freakout over a physician surplus,” said Robert Orr, a social policy analyst at the Niskanen Center in Washington, DC. At the time, miscalculations about population growth and changes in medical care delivery contributed to a moratorium on medical school enrollment that lasted until 2005.

Although medical schools have since continued to grow, expanding too quickly could result in a surplus of medical graduates with nowhere to do their residencies. That’s because of the other major bottleneck in the pipeline — the low number of residency positions. This year’s 36,000 first-year residency slots are inadequate to meet the US need for physicians and inadequate to provide training positions for all the applicants seeking them — and like the dearth of medical school seats, it is a consequence of restrictions created long ago with arguably good intentions.

Since the Medicare and Medicaid Act was first passed in 1965, medical residents have been paid for mostly by the Medicare and Medicaid programs. The goal was to ensure Medicare beneficiaries had access to the best health care, which was thought to be found in teaching hospitals.

In 1983, Medicare made changes to the way it reimbursed hospitals for residency programs. At that time, it created formulas that calculated the dollar amount of residency training funds it supplied to each hospital as a percentage of that hospital’s care expenditures and its volume of Medicare patients — sort of like a restaurant tip, said Orr.

Those formulas have never been updated — and because they tie funding to the cost of care, they have resulted in better funding for hospitals providing high-cost care in high-cost (usually urban) areas.

Over the years, this inequitable distribution of residency program funding has meant that hospitals prioritizing primary care services in rural areas get less funding and fewer residents than those that perform lots of expensive procedures in cities. That leads to fewer primary care specialists, and because physicians often practice near where they train, fewer rural physicians.

This fee structure also incentivizes hospitals to raise the cost of the care they deliver, and results in lower funding for residency programs at hospitals that treat younger populations less likely to be covered by Medicare.

Worse yet, to reduce Medicare expenditures, the Balanced Budget Act of 1997 capped the number of resident slots that could be funded by Medicare each year. It also capped the number of residents each hospital could have at their 1996 levels, which meant hospitals couldn’t get additional residents even if the population they served ballooned in size. Obamacare undid this restriction in 2010, and since then, the number of residency spots has grown modestly.

In 2020, Congress passed a federal budget bill that provided for 1,000 new Medicare-funded residency slots to be added over the next five years. But that’s nowhere near enough to close the current gaps.

Money donated by private insurers funds some residency positions at “the hospitals with the prestige and market power to extract it,” said Orr, but “it’s not a super-equitable way of trying to get residents out to different hospitals where maybe the population isn’t as well served.””

“There are also some solutions that sidestep the residency bottleneck entirely. One of the more promising fixes to the physician shortage is to allow other highly trained providers, like nurse practitioners, physician assistants, and pharmacists, to practice independently of doctors. The American Medical Association has vigorously fought this change for more than 30 years, and physicians who oppose the move often cite patient safety concerns, although they are not substantiated by safety studies.

Much of the real motivation to prevent these providers from practicing independently may be about money and professional sovereignty; private practice doctors in particular are financially disincentivized from expanding the scope of other practitioners.”

Physicians Should Be Allowed To Practice Across State Lines—and Not Just During a Pandemic

“Medical professionals are typically licensed on a state-by-state basis, so a doctor licensed in one state can’t practice in another without receiving an additional license. The patchwork of licensing requirements across states is a major obstacle to the use of telemedicine because physicians are generally only permitted to provide telemedicine services to patients in states where they are licensed.

States are recognizing the cost of these onerous regulations in light of the current crisis. Over the past few weeks, governors and medical boards in every state except for Alaska, Arkansas, and Minnesota have temporarily suspended their licensing rules to allow out-of-state physicians to work in their state. Most of them have also waived restrictions on the use of telemedicine across state lines.”

“Some states are in greater need of physicians than others. On average, there are roughly 263 physicians per 100,000 people in the United States. But in Massachusetts, there are 449 physicians compared to just 191 in Mississippi. Moreover, the number of COVID-19 cases is expected to peak at different times in each state, so the peak demand for health care providers will vary. Allowing physicians to practice across state lines grants them flexibility to help where they are needed most.”

“Beyond the current crisis, telemedicine has the potential to connect patients with specialists across the country. Telemedicine may also reduce inefficiencies that result from schedule gaps, unexpected appointment cancellations, and the uneven geographic distribution of physicians.

A growing, aging population is expected to generate a national shortage of nearly 220,000 physicians by 2032. As with the current distribution of physicians, shortages will not be evenly distributed across states. Regional projections from the Department of Health and Human Services (HHS) indicate that the Southeast will have a shortage of approximately 13,860 primary care physicians as early as 2025, while the Northeast will have a surplus of around 810 physicians. Telemedicine offers a solution, but states will need to reform their licensing laws for the technology to reach its full potential.”

How Doctors Broke Health Care

“Nearly 18 percent of America’s economy is devoted to spending on health care, far more than the share in any comparable country. And although the U.S. medical system provides some of the best health care in the world, it does so only for those who can afford it. Moreover, fragmented service delivery undercuts overall quality. A decade after passage of the Affordable Care Act (ACA), health care spending is still eating up government and household budgets, nearly 28 million Americans remain uninsured, and costs continue bounding upward.”

“Too many of today’s policy “solutions” build upon the faulty insurance company model that currently organizes U.S. health care—a model that was concocted by the American Medical Association (AMA) in the 1930s as a way to protect the professional status and earning power of its members. It resulted in care that is expensive, bureaucratic, and frustrating for both patients and caregivers.”

The US needs foreign doctors and nurses to fight coronavirus. Immigration policy isn’t helping.

“Right now, the biggest worry is whether the medical system has enough ventilators and protective equipment to treat patients with Covid-19, the disease caused by the novel coronavirus.
But another troubling shortage is on the horizon: doctors, nurses, and other health care personnel.

As patient demand continues to ramp up nationwide and more health care workers are unable to show up for work, either because they contract the virus or because they have to self-quarantine, doctor shortages are a real possibility”

“One solution is to make it easier to bring in doctors and nurses from abroad.”

“even before the current crisis, the immigration system made it difficult for foreign doctors and nurses to work in the US and go where they’re needed. Doctors may face long wait times for green cards, restrictions on where they can settle geographically, and limitations on where they can practice while they’re waiting for a green card. Nurses, meanwhile, also face long waits for green cards and can’t come to the US under temporary skilled worker visas.

The implications of a shortage would be devastating, both to overworked personnel and to the patients for whom receiving medical attention could be a life-or-death matter. But it’s a problem that more immigration could easily fix”

“Not only does the current system make it exceedingly difficult for doctors to stay in the US long-term, but it also severely restricts where in the US they can go.”