Bill Complicates Drive to Add Primary-Care Doctors
Janet Adamy, Wall Street Journal, November 27, 2009
A handful of Democratic senators are pushing to change pending health-care legislation so that it
would help increase the country's stock of primary-care doctors, heeding warnings that the bill
may exacerbate the difficulty some Americans already have in finding a doctor.
More than 30 million Americans would get health insurance under the health-care overhaul that
passed through the House and a similar bill moving forward in the Senate. If that does indeed
happen, many previously uninsured people who haven't had a regular doctor before will need a
primary-care physician. Demand would also likely increase for nurse practitioners and general
surgeons.
But pressure to keep down the legislation's cost led Democrats to exclude one way of alleviating
the projected shortage. Medical colleges, backed by some Democrats, want funding for 15,000
more slots for graduate medical residencies in primary care and general surgery. The
government currently pays part of the cost for such residencies through Medicare.
Senate Majority Leader Harry Reid co-sponsored a separate bill to do just that this spring. But
when doctors pressed him to include the measure in the broader health-care overhaul he crafted,
the Nevada Democrat balked because the estimated $10 billion to $15 billion cost over a decade
would inflate the bill's overall price too much.
Now, some Democrats are preparing to press for a more limited expansion of residency slots
once the Senate begins hashing out the bill on the floor next week. Sen. Charles Schumer of New
York plans to introduce an amendment that would add about 2,000 residency spots to the current
100,000. The amendment would give first priority to primary-care doctors and general surgeons.
The scaled-back effort underscores the pressures facing Senate Democrats as they embark on
altering a 2,074-page bill that will touch almost every American and remake an industry that
accounts for nearly one-sixth of the nation's economy. President Barack Obama has set the cost
ceiling for the bill at $900 billion over a decade. That means even widely supported provisions are
getting left out because they add to its estimated $848 billion current tab.
"Ideally, we should have the 15,000 that we asked for," Mr. Schumer said of the proposed
expansion of residency positions. "But we're all trying to keep the costs of the bill down."
Even without an insurance expansion, the American Medical Association estimates the country
will be short 85,000 doctors in primary care, cardiology, oncology and general surgery by 2020.
The shortage is especially acute in certain rural areas. Doctors say the relatively lower prestige
and pay in primary care tends to drive medical students into more-lucrative specialties.
Both the House and Senate bills contain provisions to address the issue. The Senate bill
increases funding for the National Health Service Corps, which helps repay student loans for
doctors, nurse practitioners and dentists who work in underserved parts of the country. Primarycare doctors who participate can get up to $50,000 of loans repaid. The bill also reallocates some
unused residency slots toward higher-need areas.
Atul Grover, chief advocacy officer for the Association of American Medical Colleges, said such
changes are significant but don't go far enough. Government funding for medical-residency slots
hasn't increased since 1997 because of a budget-control bill that froze funding for the spots.
"We're not going to have enough doctors, even if you don't consider expanding insurance
coverage to millions of people," Dr. Grover said. "It's just a question of time before it leads to
longer waits for all of us to get in to see the doctor."
In Massachusetts, which required people to carry health insurance starting in 2006, wait times to
see certain doctors are rising and community hospitals have more acute shortages of family and
internal-medicine doctors, according to a study by the Massachusetts Medical Society. Forty
percent of family-medicine physicians no longer accepted new patients as of this year, up from
30% in 2007, the study found.
Still, Partners HealthCare, the state's largest health system, said it had generally absorbed the
influx of patients. Partners HealthCare got a private sponsor to help fund its own doctor loanforgiveness programs, and offered reimbursement of up to $75,000 in debt per student.
"I don't think you'd find a lot of horror stories about long waits or people having a bad experience,"
said chief operating officer Tom Glynn.
Nancy Nielsen, immediate past president of the American Medical Association, predicted a
similar outcome nationally if the bills pass. "I think we can indeed anticipate a surge, and then it
will settle out," she said, as the initial need for care peters out.
At the University of Arkansas for Medical Sciences, which runs medical training and care facilities
throughout the state, Chancellor Dan Rahn isn't so sure. He is pushing for more spots to train
doctors in internal medicine, family practice, gynecology and pediatrics, particularly in rural areas.
He said psychiatrists from Little Rock must drive 190 miles to care for patients in the northwest
part of the state because the university doesn't have funding to train residents there.
He has a potentially powerful ally in his plight: Sen. Blanche Lincoln, a moderate Democrat whom
Mr. Reid is heavily courting to support the bill. Dr. Rahn plans to press his case in a meeting with
her next week.