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Stethescope on top of pile of money
The U.S. is going to need some 16,000 new primary care providers in the next few years as the Affordable Care Act expands health insurance coverage. That's the conclusion of a report from Sen. Bernie Sanders (I-VT) and the Select Committee on Aging. This isn't news, and it's not something the writers of the Affordable Care Act weren't aware of. In fact, they planned for it. They created the National Health Care Workforce Commission in the law to help identify ways in which the primary care workforce could be grown.

But here's the problem. The 15 members of the commission have been named, but it's never met. Why? Because it's never been funded. Sanders held a hearing on Tuesday to push for a renewed effort to get this commission off the ground, noting that 57 million Americans lack ready access to primary care.

If House Republicans have their way, those millions of Americans (aka, constituents) will continue to lack access to care. Because the House Republicans have taken the commission hostage. Never mind that the $3 million required to get the commission up and running is a tiny, tiny sum. Never mind that the shortage of primary care professionals has been an ongoing problem and will continue to be regardless of the fact that Obamacare is law of the land. Trying to fix that shortage is part of Obamacare, so it must die. If they can't repeal it, they'll kill it by refusing to fund it. Any people killed in the meantime by their lack of access to care are just unfortunate innocent bystanders.

Originally posted to Joan McCarter on Wed Jan 30, 2013 at 10:12 AM PST.

Also republished by Daily Kos.

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Comment Preferences

  •  Cough cough, nurse practitioners, cough cough. (10+ / 0-)

    Most doctors want to go for the big money of specialization.  I think nurse practitioners are going to provide more and more of what was the general practitioner slot in years to come.  But even if the commission gets funded, I imagine the AMA will lobby hard to keep the money flowing to training new doctors.

    •  Both GPs and NPs (3+ / 0-)
      Recommended by:
      Samer, Gorette, Catte Nappe

      We shouldn't even suggest the escape hatch of "either/or."

      When you are right you cannot be too radical; when you are wrong, you cannot be too conservative. --Martin Luther King Jr.

      by Egalitare on Wed Jan 30, 2013 at 10:30:48 AM PST

      [ Parent ]

    •  When one of our local doctors retired (6+ / 0-)

      his practice was purchased by another doctor in town. Rather than consolidate the practice at one location, the office was kept open and run by a nurse practitioner under the guidance of the medical doctor.

      So for most routine visits the patients will be seen by the nurse and that's that.

      There was an article about the new arrangement in the local paper and I was a bit surprised that they didn't consolidate both practices at a single location especially since both offices are within a couple of miles of each other.

      This is a rural area east of Sacramento in the Sierra Nevada foothills and we have a severe shortage of doctors. So I think we will see more of this in the future.

      The only trouble with retirement is...I never get a day off!

      by Mr Robert on Wed Jan 30, 2013 at 11:00:47 AM PST

      [ Parent ]

    •  I've met really excellent nurse practictioners, (0+ / 0-)

      but the ones in my doctor's practice are incurious and unimaginative. They say what they have to say, but can't answer questions. For that I need to talk to the doctor.

      "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

      by Lily O Lady on Wed Jan 30, 2013 at 11:06:06 AM PST

      [ Parent ]

      •  Hmm (2+ / 0-)
        Recommended by:
        Justanothernyer, marina

        Can't answer questions, why?  They don't know and don't care to find out - or the doc has warned them to zip it up and let him handle it?  

        "No one life is more important than another. No one voice is more valid than another. Each life is a treasure. Each voice deserves to be heard." Patriot Daily News Clearinghouse & Onomastic

        by Catte Nappe on Wed Jan 30, 2013 at 11:38:59 AM PST

        [ Parent ]

        •  The doctor wants them to handle it, but they (0+ / 0-)

          just don't have a very deep understanding of things, and apparently don't know how to find out or don't care.

          "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

          by Lily O Lady on Wed Jan 30, 2013 at 11:47:39 AM PST

          [ Parent ]

        •  "why?' (2+ / 0-)
          Recommended by:
          Catte Nappe, hester

          ultimately it is the M.D. that is responsible.
          i suspect that the ogre of malpractice suits may be in play here as to being a reason why.

          •  That was one reason I speculated on (0+ / 0-)

            However, LilyO's response indicates this doc is willing for them to assume more responsibility, but they aren't inclined to.

            I don't know them, of course, but I still think there's a high likelihood of docs under utilizing NP capability - whether malpractice concern or God complex or poor understanding of team management.

            "No one life is more important than another. No one voice is more valid than another. Each life is a treasure. Each voice deserves to be heard." Patriot Daily News Clearinghouse & Onomastic

            by Catte Nappe on Wed Jan 30, 2013 at 03:27:59 PM PST

            [ Parent ]

            •  I love your sig, Catte. and it brings me around (2+ / 0-)
              Recommended by:
              Catte Nappe, NancyWH

              to the diary's closing lines:

              If they can't repeal it, they'll kill it by refusing to fund it. Any people killed in the meantime by their lack of access to care are just unfortunate innocent bystanders.
              I guess all the collateral damage caused by wars wasn't enough for the Republicans.  They now demand the death of our own citizens - their own constituents - on the altar of their own ideology.

              "In this world of sin and sorrow there is always something to be thankful for; as for me, I rejoice that I am not a Republican." - H. L. Mencken

              by SueDe on Fri Feb 01, 2013 at 07:16:45 PM PST

              [ Parent ]

      •  Sometimes it has to do with licensing (1+ / 0-)
        Recommended by:
        Jojos Mojo

        and that will vary by state, since the licensing boards are organized by state.

        I didn't know until recently that nurse practitioners do different things in VA than they do in NC, for example.  

        Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

        by a gilas girl on Wed Jan 30, 2013 at 11:47:41 AM PST

        [ Parent ]

        •  Well, one of them kept telling my husband (0+ / 0-)

          that he needed to spend some time at the gym, but he spends an average of an hour a day. He is not obese or really even overweight. They hadn't taken his body type into account. He got sick of it along with some other problems and changed practices.

          "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

          by Lily O Lady on Wed Jan 30, 2013 at 11:57:18 AM PST

          [ Parent ]

          •  And then... (2+ / 0-)
            Recommended by:
            Lily O Lady, Jojos Mojo

            ...there always seem to be individuals who work in jobs and aren't particularly conscientious about their jobs.

            I imagine the ranks of nurse practitioners have their fair share of those types as does any profession.

            Sorry to hear your husband had such a hard time.  

            Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

            by a gilas girl on Wed Jan 30, 2013 at 12:01:09 PM PST

            [ Parent ]

    •  Nurse practitioners are great (6+ / 0-)

      My primary care giver is one. However, I suspect more docs would consider primary care if debt for medical school weren't so massive, and/or payment for roviding care weren't so pitiful. We should strive for adequate numbers of both.

      "No one life is more important than another. No one voice is more valid than another. Each life is a treasure. Each voice deserves to be heard." Patriot Daily News Clearinghouse & Onomastic

      by Catte Nappe on Wed Jan 30, 2013 at 11:37:16 AM PST

      [ Parent ]

      •  CN - I think this is an important issue (5+ / 0-)

        I think that having the federal government forgive some portion of medical school debt in return for a physician pursuing a family practice residency is one of the solutions.

        "let's talk about that"

        by VClib on Wed Jan 30, 2013 at 11:57:36 AM PST

        [ Parent ]

        •  One of the things never discussed is the (0+ / 0-)

          medicare contribution of post grad medical education. A doctor can get licensed with as little as one year of training - basically you do a flex internship and you're good to go except you really don't know anything. So most docs do 3-5 years depending upon the specialty. The get paid a stipend during that time, and they consume huge amounts of attending physician time. Medicare reimburses for these training expenses to the tune of about $150,000 per year per trainee. So a young general surgeon just out of training and specialty board eligible in a year, has her own investment in the cost of college and medical school (which can be substantial) plus the public investment of $750,000 in post graduate training. Moreover, the physicians doing the training, doctors in academic practice, give up substantial income in order to do teaching and research. I hate to offend my primary care colleagues, but for the most part they waste the training they received and their patients pay for it. My primary doc is an internist. Four years of medical school and three years of post graduate medical training, plus 15 years in practice, and he is incapable of draining a skin abscess - he'll refer you to a surgeon. Most internists know how to manage a half dozen diseases in their sleep and for the rest they've mostly gotten too lazy to bother. Rather than knowing the diseases, they know a colleague. It has gotten more and more pathetic. Not that I didn't love practicing medicine, I did, but there was an awful lot of bullshit and the pile got mighty high during my career.

      •  We also have a surprising number of docs (1+ / 0-)
        Recommended by:
        Dr Erich Bloodaxe RN

        who aren't practicing due to various logistical and job satisfaction issues.

        I know one who is supporting herself as an artist and making more than she did with her practice. Another is working as an exercise instructor.

        Fry, don't be a hero! It's not covered by our health plan!

        by elfling on Wed Jan 30, 2013 at 02:03:10 PM PST

        [ Parent ]

    •  Yep. This by default is the future of primary care (0+ / 0-)

      Organized medicine, AKA the AMA and all the various specialty societies, has had a laser-like focus on physician income and financial well-being over the past...well, forever. To its shame, the American Academy of Family Physicians has seemed to devote more resources to fighting against independent practice by nurse practitioners and physician assistants than to increasing the number of family physicians.

      Consequently, the future has already been decided. Over the next 25 years, primary care will be predominantly provided by mid-level providers like physician assistants and nurse practitioners. It's too late to train enough primary care doctors to make a dent in the growing shortage.

    •  Yeah, and I was going to post a comment (0+ / 0-)

      that maybe the title of the diary should be changed. ". . . Shortage of Providers" would be more accurate.

  •  I agree this is a huge problem (9+ / 0-)

    And think it needs a big dose of federal help, starting with the first three million to get started. However, it will take a decade of significant investment by the federal government to bring the number of primary care clinicians in line with what we need. This is one element that could actually bend the national healthcare cost curve. Increasing the number of physicians, physician assistants, and nurse practitioners in each graduating class takes a large commitment by the federal government and the participating medical schools. This is something that should have started in the Clinton administration. The idea that anything could be done by 2014 is fiction.

    "let's talk about that"

    by VClib on Wed Jan 30, 2013 at 10:23:02 AM PST

    •  Friendly amendment: a big dose of federal help... (5+ / 0-)

      ...consistently authorized for 12-15 consecutive years minimum.

      When you are right you cannot be too radical; when you are wrong, you cannot be too conservative. --Martin Luther King Jr.

      by Egalitare on Wed Jan 30, 2013 at 10:29:03 AM PST

      [ Parent ]

    •  Funding authorizations are contained in the ACA. (0+ / 0-)

      The appropriations will be the continual issue.

      And bye the bye, one notes the authorizations for the entity named in this diary alone (and its related National Center for Health Workforce Analysis, which isn't mentioned, strangely enough) total well over $3M from 2010-2014. The whole workforce section can be perused here, in summary form.

    •  AMA (0+ / 0-)

      It is arguable that the first thing we need to do in nueter the AMA.  These are the people who took 30 years to admit their first women member, long after women were being licensed and serving as doctors, and spent  year history actively opposing black doctors.  In thirty years they have doubled number of black and hispanic doctors.  We can wait another 30 years, and that number  may double but still not be representative of the population

      I do not know if there is a shortage of primary care doctors.  The numbers I see is that half the doctors go into primary care.  I also see that there are geographical areas without doctors. maybe because 75% of physicians are white, and 66% of them are white, and therefore don't represent the diversity of the population, so can't represent the needs of the population.

      Yes, nurse practitioners can be a solution.  Nurses are a more diverse group.  Nurse practitioners will allow the AMA say that people are receiving good treatment, while also allow it to maintain itself as predominantly white male club.

      I, however, think that everyone should expect a well trained diagnostician and not just someone who can prescribe meds. Our problem now is that we live in a country of drug pusher, drug dealers, and drug addicts.  Few wants to feel, no one wants deal with the pain, so drugs are the answer.

      So how we do get physicians and healers.  As must as people want makle fun of it, is is a college bound culture in every  school that focuses on process and problem solving.  These are the skills of science, engineering, yes even medicin.  Prospective medical students can focus on biology instead of physics.  Every school  needs a path including Anatomy&Physiology.

      Not everyone will go to college, perhaps only 25% will, but now that 25% will be those who are qualified nto dependent on where on is born.  I don't necessarily want more people in college, I just want everyone who is capable to have a good opportunity to succeed.

      Then we need to make sure that every qualified person can go to medical school., not just those who the AMA want.  

  •  government should give away medical school (8+ / 0-)

    scholarships, increase the supply of doctors who dont owe a dime when they get out of school, so they can work 40 hour weeks at reasonable pay.

    isnt that called supply side economics?

    war is immoral. both parties are now fully complicit in the wars. bring everyone home. get to work.

    by just want to comment on Wed Jan 30, 2013 at 10:26:34 AM PST

    •  Sure, at $120,000 a pop... (2+ / 0-)
      Recommended by:
      jfromga, Mr Robert

      ...that's about $2 billion for the 16,000 needed - pretty cheap, when you think about it.

      The road to Hell is paved with pragmatism.

      by TheOrchid on Wed Jan 30, 2013 at 10:34:26 AM PST

      [ Parent ]

    •  They already subsidize the residency program (3+ / 0-)
      Recommended by:
      a gilas girl, Jojos Mojo, a2nite

      If you're a medical resident in this country, most if not all of your salary comes from the government.

      We don't want our country back, we want our country FORWARD. --Eclectablog

      by Samer on Wed Jan 30, 2013 at 10:46:21 AM PST

      [ Parent ]

      •  Samer - you are correct but it's not enough (1+ / 0-)
        Recommended by:
        Samer

        Changing the supply/demand of primary care clinicians is the first step to controlling long term healthcare costs. It will take a decade, and a much higher subsidy of primary care physician education to make a difference.

        "let's talk about that"

        by VClib on Wed Jan 30, 2013 at 12:01:21 PM PST

        [ Parent ]

        •  I didn't say it was enough. (1+ / 0-)
          Recommended by:
          VClib

          I'm just pointing out that we've already got the gubmint subsidizing doctor salaries, so funding medical students (which, to a far-too-limited extent, the government already does) isn't a ridiculous jump.

          We don't want our country back, we want our country FORWARD. --Eclectablog

          by Samer on Wed Jan 30, 2013 at 07:24:44 PM PST

          [ Parent ]

    •  Yes, and they have to work in primary care for (1+ / 0-)
      Recommended by:
      Jojos Mojo

      a certain number of years.

    •  Isn't simply a matter of medical school costs... (3+ / 0-)
      Recommended by:
      Jojos Mojo, elfling, a2nite

      ...though that is certainly one piece.

      It's also about making sure that clinical placements for the nursing, allied health professionals and para professionals have adequate proctoring personnel so that people can be trained effectively in ways that meet all licensing requirements, that new hires in the health care field remain in the field working (retention is a huge issue where I live, for example), that the delivery of care be transformed in ways that do address both workforce shortages and requirements to reduce costs.  

      A health care workforce is expensive to train, to recruit, to hire and retain.  And it requires resources across a broad swath of a society's educational and health care institutions, including public schools.  

      Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

      by a gilas girl on Wed Jan 30, 2013 at 11:56:56 AM PST

      [ Parent ]

      •  The problem with nursing is there are (0+ / 0-)

        so many more nurses than doctors. This reflects hospital and clinic ratios, plus independent practices for both.

        The American Medical Association reports that there are 920,000 physicians in the US. This is a ratio of 10 nurses to 3 physicians.
         http://www.truthaboutnursing.org/...
        Not sure if the AMA was smart enough to factor this in.
        US (2008 data) has 3.1 million RNs, with 85% being employed in nursing.
        The problem with RNs not working as nurses has grown in the last decade.  Graduates are burning out faster than ever.
        The U.S. will need to educate about 1.0 million new nurses by 2016--which is 40% the size of today's nursing workforce. (See U.S. Department of Labor "Occupational employment projections to 2016" (pdf).) The U.S. Department of Labor has predicted that the number of nurses needed in the workforce will grow by 587,000 to 3.1 million nurses by 2016--a 23% increase in the number of nurses.
        Haven't checked if this was written pre ACA. It sounds about right. I wrote a 4 page treatise and discussed it with my Congressman, Ed Perlmutter in 7/09 regarding how many nurses we would need. I specifically recommended getting boomer BSN's like me through 2 years for a NP degree. Our experience would be really helpful, and over the next 10- 15 years as we retire, more could go through the full 6 -8 years.

        The other issue is how they are calculating the length of training. 2 year programs solve dire straights, 4 year has been shown to reduce morbidity and mortality the higher the mix on a unit. Univ of CO Hosp has been limiting new hires to 4 year for at least 5 years. It has been awarded the #1 Academic Hospital in America for '11 and '12 (based on patient outcomes). A year ago it received a 4th Magnet designation - for nursing. They are done on a 3 year evaluation routine.

        Ultimately I am afraid the doctors will get the attention and $. While it would be nice for the country and the healthcare business to get it through their heads that it only works because of proper nursing care, the casualties would be really ugly. American hospitals don't want to resort to the 3rd world practice of expecting families to do much of the patient's nursing care.

        "People, even more than things, have to be restored, renewed, revived, reclaimed and redeemed; never throw out anyone. " Audrey Hepburn "A Beautiful Woman"

        by Ginny in CO on Fri Feb 01, 2013 at 07:35:17 PM PST

        [ Parent ]

    •  just want - I agree (0+ / 0-)

      But limit it to primary care, not for those who want to pursue more lucrative specialties, or sub specialties.

      "let's talk about that"

      by VClib on Wed Jan 30, 2013 at 11:59:25 AM PST

      [ Parent ]

    •  They already do... (0+ / 0-)

      ...give out scholarships. They typically have a post-training service requirement as a condition to be done in medically underserved locations. There are always more applicants for these scholarships than funds available for them.

      "Reality divorced the wingnuts after the wingnuts were discovered to be fucking goofy." - DWG

      by Jojos Mojo on Wed Jan 30, 2013 at 01:06:57 PM PST

      [ Parent ]

  •  The problem isn't money alone (6+ / 0-)
    Recommended by:
    Catte Nappe, VClib, elfling, a2nite, hester, marina

    What I hear from friends and family is that primary care physicians increasingly feel a loss of status.  They are pressured by insurance companies and by healthcare systems.  They have much less control than they once had.  The increasing pressure to cut costs does pressure providers because insurance companies and healthcare systems insist on maintaining profits.  Evidence based medicine is necessary to improve quality and reduce costs but when implemented ineffectively it infuriates experienced physicians.  

  •  This is why I hate hate hate Republicans. (2+ / 0-)
    Recommended by:
    llywrch, a2nite

    Their downright addiction to doing the wrong thing, doing what will hurt the people of this country. And not caring an iota because they want to fail the president and they want to keep being elected to their powerful positions.

    For money and power they are corrupt and will do any old destructive thing they want in order to keep it.

    Kill thousands of Americans? Sure.

    IDIOT REPUBLICANS are beneath contempt.

    "extreme concentration of income is incompatible with real democracy.... the truth is that the whole nature of our society is at stake." Paul Krugman

    by Gorette on Wed Jan 30, 2013 at 11:01:54 AM PST

  •  It's not a problem for them. THEY have (1+ / 0-)
    Recommended by:
    a2nite

    doctors and all the medical care they need.

    "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

    by Lily O Lady on Wed Jan 30, 2013 at 11:06:43 AM PST

  •  Not a problem (1+ / 0-)
    Recommended by:
    llywrch

    They're just going to declare a "dire shortage of physicians" and import extra doctors from India and elsewhere, promote some nurses to "nurse practitioners" and "physician assistants", and the promote some nursing assistants to nurses.    I suspect every actual doctor will be running a stable of 5 or 6 or more nurse practitioners before long.   Then, in the poorer areas, they'll just add 6-9 months to the wait time for an appointment.

    We wouldn't want to do something counter-productive like investing federal money in the recruitment and training of U.S. doctors.

  •  Actually (0+ / 0-)

    it is being addressed in many ways with state and local initiatives.  The CDC has many Community Transformation Grants ongoing at present and many of these are addressing issues of the Health Care Work Force.  I know; I'm part of a special initiative team that's convened under a local county-wide CTG funded partnership.

    But yeah, it's spotty.  Still it is something that's not just on the radar but the top of many lists of several initiatives association with the ACA.  (All I hear day after day is "Health Workforce" Issues at work)

    ;-)

    Words can sometimes, in moments of grace, attain the quality of deeds. --Elie Wiesel

    by a gilas girl on Wed Jan 30, 2013 at 11:44:48 AM PST

  •  I have every hope that the GOP (2+ / 0-)
    Recommended by:
    Ginny in CO, NancyWH

    will fade into a minority party, thanks to a rising demographic wave that will envelope everything soon. Will it happen before too many people have to die? I can only hope.

    It's here they got the range/ and the machinery for change/ and it's here they got the spiritual thirst. --Leonard Cohen

    by karmsy on Fri Feb 01, 2013 at 06:39:20 PM PST

    •  I'm afraid that is going to be (2+ / 0-)
      Recommended by:
      karmsy, NancyWH

      " before how many people have to die?" A disproportionate number will be from the rising demographic wave for sure.

      As much as I would like to get well enough to go back to work is as much as I don't want to go back to nursing. Which will decrease my salary by about 65%.

      "People, even more than things, have to be restored, renewed, revived, reclaimed and redeemed; never throw out anyone. " Audrey Hepburn "A Beautiful Woman"

      by Ginny in CO on Fri Feb 01, 2013 at 07:42:42 PM PST

      [ Parent ]

  •  No need.... (0+ / 0-)

    ....the almighty free market knows best, no matter how distorted it is in the current state as influenced by the AMA.

  •  We need a subsidized federal medical school. (0+ / 0-)

    it fitfully blows, half conceals, half discloses

    by Addison on Fri Feb 01, 2013 at 06:48:22 PM PST

  •  Here's an idea for improving it (0+ / 0-)

    Remove the artificial limits on the number of people allowed to graduate from medical school, and the number allowed to practice in a particular area. Those limits are great if all you care about is forced scarcity and managing income levels, for patients and the people who want to actually practice medicine, well not so great.

    A friends brother is an anesthesiologist in Knoxville. He didn't want to me, he wanted to be a urologist as I recall. They had "too many" (5 at the time) so he had no choice but to go for anesthesiology.I imagine an enormous number of people, like I was, are unaware of these limits. If people want to practice, want to goto med school, let them and let them succeed of fail based on their ability not a limit quota. Stop telling them "oh..we've got enough."

    Nicht durch Zorn, sondern durch Lachen tödtet man. ~Nietzsche

    by somewierdguy on Fri Feb 01, 2013 at 06:51:17 PM PST

  •  I'm sorry but (0+ / 0-)

    We're going to spend 3 million dollars. To help hire 16 thousand new doctors? Like, when people (who now can pay!) need to see a doctor, and the free market wouldn't naturally work that out?

    And as stated above, FNP's are a ch better alternative.

  •  Obama administration (0+ / 0-)

    should get together with AMA and medical schools to carve out a new licensed specialty that is both primary care physician and the secondary specialty practice and incentive it pronto;

    Behind Reagan the Right convinced white middle and working class men their interests lay with rich plutocrats, that the real victims in America were Ayn Rand’s supermen whose economic dynamism needed to be “unchained.” ~ Robert Parry

    by anyname on Fri Feb 01, 2013 at 06:56:45 PM PST

  •  How many fewer specialists (0+ / 0-)

    ...will be needed?

    BTW, there is a very simple way to deal with this.  Increase Medicare/Medicaid payments for primary care physicians and reduce payment rates dramatically for specialists.

    50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

    by TarheelDem on Fri Feb 01, 2013 at 07:19:49 PM PST

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