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Most ACA critics now grudgingly admit that people are getting insured after all, but they say there's a catch. "Where are we going to get all the doctors?" a social worker asked me recently. "We're overwhelmed as it is." A letter in the local paper said, "People aren't really covered unless someone accepts their 'insurance', and if nobody is accepting it, then why should people pay for it?"

I briefly answered the letter writer online, saying that the solution was in the provisions of the Affordable Care Act to increase the primary care workforce not only with more primary care doctors but also more nurses, nurse-practitioners and physician assistants. I was then curious to find out more about what the ACA has been doing to upgrade primary care in the U.S. and found that it has already made major improvements.

To train more primary care physicians and other personnel, the ACA has provided scholarships and loans. For example, in 2011 the White House reported that the Affordable Care Act’s Prevention and Public Health Fund was helping to train 600 new nurse practitioners and nurse midwives by 2015 and "the investment in Nurse Managed Clinics is projected to help train more than 900 nurses by 2013 and serve 94,000 patients."

To further strengthen primary care, the ACA allocated $1.5 billion over five years to the National Health Service Corps, founded in 1972. In 2011, up to $28 million was available for NHSC scholarships for physicians, dentists, nurse practitioners, nurse-midwives, and physician assistants. Graduates agree to work for several years in areas where there is a shortage of health care professionals. In addition, the ACA provided $11 billion for Federally Qualified Health Centers, 2011-2015, serving 15-20 million more patients by 2015. The ACA has also enabled community health centers to add 3,000 nursing positions since 2009.

To encourage more doctors to accept Medicare and Medicaid patients, the law increased primary care reimbursement rates. It allotted $3.5 billion for a 10% pay hike in 2011-2016 for Medicare providers, and $8.3 billion for Medicaid providers for the years 2013-2014. Sarah Kliff, who writes about the ACA for the Washington Post, explained in Obamacare is about to give Medicaid docs a 73 percent raise that the increased pay is temporary, but if it brings more doctors to the program, higher Medicaid rates may be maintained in the future.

The primary care physician shortage could be reduced by 50% or more by 2025, according to a Forbes article: Doctor Shortage Could Ease As Obamacare Boosts Nurses, Physician Assistants. The article cautions, however, that this may require "changes in policy, such as laws to expand the scope of practice for nurse practitioners and physician assistants, and changes in acceptance, on the part of providers and patients, of new models of care."  

From what I've seen in anti-Obamacare letters to the editor, the writers think the ACA is only about health insurance. However, the ACA does much more to reform health care in the U.S. The breadth and complexity of the law can be seen in its ten titles.

Title I. Quality, Affordable Health Care for All Americans
Title II. The Role of Public Programs
Title III. Improving the Quality and Efficiency of Health Care
Title IV. Prevention of Chronic Disease and Improving Public Health
Title V. Health Care Workforce
Title VI. Transparency and Program Integrity
Title VII. Improving Access to Innovative Medical Therapies
Title VIII. Community Living Assistance Services and Supports Act (CLASS Act)
Title IX. Revenue Provisions
Title X. Reauthorization of the Indian Health Care Improvement Act

For a brief outline of each title and to read the law section by section, see http://www.hhs.gov/...

Cross-posted at ACA Signups.

Wed Apr 09, 2014 at 11:15 AM PT: An article dated April 8th says: Primary Care Shortage? Not For The Insured, Study Shows. Researchers posing as nonelderly adult patients made nearly 13,000 calls to primary care practices in 10 states between fall 2012 and spring 2013. When researchers said they had insurance, they were able to make an appointment about 85 percent of the time. Those calling as Medicaid patients were successful getting appointments about 60 percent of the time. Researchers who said they were uninsured and couldn’t pay much were four times less likely to get in compared with those calling with Medicaid.


Originally posted to ybruti on Tue Feb 18, 2014 at 08:48 AM PST.

Also republished by Community Spotlight.

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Comment Preferences

  •  Any talking point Republican should know this: (48+ / 0-)

    When there is a shortage in the market, the market responds by increasing the supply of whatever there is a shortage of.

    Don't have enough doctors and other health care practice professionals, and there is a robust insurance program willing to pay for the service, and millions of customers demanding that service, and willing to pay for it, the market responds to increased demand.

    So, ObamaCares increases the demand for health care services across the board, and provides the means to pay the providers, VOILA!!! the market responds.

    That's so simple, even a Republican can understand it.

    Republicans are like alligators. All mouth and no ears.

    by Ohiodem1 on Tue Feb 18, 2014 at 08:55:56 AM PST

  •  2% (3+ / 0-)
    Recommended by:
    VClib, doingbusinessas, hmi

    A few years ago I read that only 2% of medical students surveryed intended to become general practitioners.  The others wanted to be specialists.  I'd like to see today's numbers.  

    Never underestimate the power of Human Stupidity.

    by Orla on Tue Feb 18, 2014 at 09:10:33 AM PST

  •  So the obvious solution is. . . . (14+ / 0-)

    to make sure that only the elite have access to health care, so there won't be a shortage or any waiting for them.

    I mean, we do that with lobster and truffles and the best champagne -- ration by price, and then there is "enough" to meet the demand. So why not health care?

  •  Two problems (5+ / 0-)

    Increasing the number of doctors by increasing the number of nurse practitioners still doesn't increase the number of doctors.  The two professions are not equivalent, even if patients call the nurse practitioners doctor.  Most of what is learned is in residencies and fellowships, which the nurse practitioners don't do much of.

    Increasing Medicare and Medicaid rates by 73% is still not that much.  In the case of an ordinary visit, in my area, the reimbursement would increase from $38 to $65.  The rates vary by geographical area.  Reimbursement for a stress test (which takes up to an hour if you talk to the patient at all afterward) would increase from $50 to $87.  This is why physicians are becoming hospital systems employees.  They are then not responsible for the 50-70% overhead.

    That said, I saw all persons regardless of pay source, as it was my duty as a citizen, I thought.  

    •  What? (2+ / 0-)
      Recommended by:
      greengemini, Kevskos

      "Most of what is learned is in residencies and fellowships, which the nurse practitioners don't do much of."

      What the hell does that mean?  Are you saying NP don't know what they're doing?

      •  No, I am saying that nurse practitioners may be (1+ / 0-)
        Recommended by:
        Savvy

        good, but they don't do the years and years and years of training that doctors do, so they may be good enough for most things, but not all things.  They are not equivalent.  So by increasing the numbers of nurse practitioners, you are not increasing the number of doctors (which is what the headline says is the solution).  

        And in our state, physician's assistants have to be assigned to a particular doctor so they do a lot of work, but aren't doctors either. They work under the jurisdiction of a doctor, attached to the doctor's license.

        Our state being Oregon, OregonWetDog.

        One of the plans is to increase training of nurse practitioners from the master's degree level to PhD, and to increase level of pharmacists and physical therapists as well to the PhD level, but then it is more difficult for these students to get through their courses, and then of course, they will also have potentially large student debts, just like doctors do, so they will also need some financial support most likely.

        •  The headline makes asumptions (9+ / 0-)

          It assumes that we need more doctors, when it is clear what we need is more primary care providers. The person being quoted in the headline presumably hasn't taken into account that much of what is done in a primary care practice doesn't require a doctor.

          I see a nurse practitioner. She works in a doctors's office and, as you describe, is attached to his license. In the more than five years I've been going to her I haven't needed to escalate to the doc for anything, but she has referred me to an outside specialist for one situation. Mr. Nappe sees the same NP, and has been going much longer. She is arranging his next appointment with the doc because he hasn't seen one in years, himself.

          “Texas is a so-called red state, but you’ve got 10 million Democrats here in Texas. And …, there are a whole lot of people here in Texas who need us, and who need us to fight for them.” President Obama

          by Catte Nappe on Tue Feb 18, 2014 at 11:49:57 AM PST

          [ Parent ]

        •  almost all Pharmacists and Physical Thereapists (1+ / 0-)
          Recommended by:
          ybruti

          go through a PHD program already.  

          Not that it makes them any better at their jobs.  There is a reason they call it the "practice of medicine".

          Yes, NPs and PAs can take up some of the load of the influx of new patients, if those patients are not too complex.  NPs and PAs, on average, don't have the expertise to handle complex patients with multiple co-morbidities

    •  For GP stuff, a nurse does just fine (14+ / 0-)

      My practice replaced the OB/GYN with a nurse practitioner as the main point of contact for wellness checkups, leaving the doctor for more complex things.  The NP can do a wellness check just as well and just as efficiently as a doctor, but if she sees something unusual she refers you to him in-house in about fifteen minutes.

      This kind of team-care is becoming more common in practices.  

      The Cake is a lie. In Pie there is Truth. ~ Fordmandalay

      by catwho on Tue Feb 18, 2014 at 11:28:15 AM PST

      [ Parent ]

    •  I would say though that much of (9+ / 0-)

      what doctors learn isn't all that relevant to daily practice, and that we tend to misuse doctors for much of our health care work.

      For example, pediatricians spend a lot of time learning to intubate an infant. But in an office setting, they spend a lot more of their time talking about the importance and proper use of car seats and giving advice about feeding and baby safety... which are not topics that are heavily covered in medical school.

      Certainly that information is important. But we might be better off having it presented by people who work with physicians who are especially trained in those fields, rather than assuming that skill at intubating an infant automatically leads to car seat expertise.

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

      by elfling on Tue Feb 18, 2014 at 11:31:01 AM PST

      [ Parent ]

      •  The reason they need to learn to intubate is that (2+ / 0-)
        Recommended by:
        ybruti, Savvy

        they attend births or other hospital work when they are on call.  There is a whole other job besides the office work.  I agree with your premise that a lot of what doctors do is education that others could provide, if the society starts to think that is acceptable.

        An incredible amount of time is spent on the electronic health record--as much time documenting stuff as actually doing the appointment.  

        •  My point isn't that they shouldn't learn to (3+ / 0-)
          Recommended by:
          ybruti, Cardinal Fang, Kevskos

          to intubate and do other highly skilled tasks.

          My point is that much of the time physicians, especially pediatricians, spend with patients is routine and involves topics not taught in medical school.

          Thus, they might be better presented by other health care professionals, and a lot of it can be presented in a small group. There's no reason you need to give the car seat information one on one to each parent.

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

          by elfling on Tue Feb 18, 2014 at 12:35:34 PM PST

          [ Parent ]

          •  I agree totally. (3+ / 0-)
            Recommended by:
            ybruti, elfling, Savvy

            My point is that the parents have to appreciate the doctor's time will be limited, and that they won't criticize the doctor for not having a "great bedside manner" if they don't linger talking about this stuff.

            Also, most people are not aware that much of the physical exam is done in conversation.  We are observing the interactions of the family, the speech and motor skills of the kid, how the kid breathes, the skin of the kid--so on.  It is not a complete waste of time, though the exact content of the conversation could be done by almost anybody.

            •  But NPs can also do well-child checkups (5+ / 0-)

              Nurse practitioners can also observe interactions, see that the childs' speech and motor skills are on track, notice the skin of the kid and so on.  No one is saying that healthy children should not have checkups with health care providers. They should. But they don't necessarily need checkups with doctors. Other health care providers, like nurse practitioners, can handle many medical tasks.

      •  I think that there are a lot (1+ / 0-)
        Recommended by:
        Savvy

        of people on here making judgements on how physicians work, and have never spent a day working in healthcare.

  •  There aren't enough doctors (12+ / 0-)

    But it's not like the market has known this was going to happen for a couple decades and not done anything. During the '90s, there was 1 new medical school graduating class in the US. From 2000 to 2009, that number increased to 11. More than a 10 fold increase in new schools. And from 2010 to 2019, that number will increase yet again to 18 new schools, with more than half of them graduating their first class from 2010 to 2014. Those new schools that started last decade all have doctors in the workforce now or finishing their residencies soon. Many that have just opened recently will have their graduates practicing by the end of this decade.

  •  US has 2.4 doctors per 1000 people. It's slightly (1+ / 0-)
    Recommended by:
    elfling

    below average for developed countries (that would be around 3-3.5) but not that much.

  •  The issue will be Medicaid (3+ / 0-)
    Recommended by:
    ybruti, catwho, MGross

    Many, in some states a majority, of doctors won't accept new Medicaid patients because of the low reimbursement rate. In some states that number is close to 70% (doctors who will not accept new medicaid patients).

  •  Some practices have anticompetitive... (8+ / 0-)

    ...language in their contracts. My sister-in-law worked for one such practice, and they worked her to exhaustion. When she left the practice, she was still bound by the contract for a period of time, so she went to work in the insurance business, doing refusals.

    There's one of your problems.

    And then there's that cost -of-education problem...

    Oh, and insurance, too...

    Float like a manhole cover, sting like a sash weight! Clean Coal Is A Clinker!

    by JeffW on Tue Feb 18, 2014 at 10:31:15 AM PST

    •  That kind of non-compete is not legal in (5+ / 0-)

      all states. It shouldn't be legal in any of them, IMHO.

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

      by elfling on Tue Feb 18, 2014 at 11:32:15 AM PST

      [ Parent ]

      •  She lives in Maryland... (2+ / 0-)
        Recommended by:
        Lily O Lady, Calamity Jean

        ...and I don't know the laws governing contracts there.

        I do know that she worked like a dog in that practice, and her work now is a lot less tiring. But when you're the only gerontollogist in the practice, well...

        Float like a manhole cover, sting like a sash weight! Clean Coal Is A Clinker!

        by JeffW on Tue Feb 18, 2014 at 11:37:38 AM PST

        [ Parent ]

    •  I was able to beat a noncompete clause by (2+ / 0-)
      Recommended by:
      ybruti, Calamity Jean

      documenting that they broke the contract first by overworking me without providing enough support.  I was working over 80 hours a week most weeks.  

      I figured I could do this for a time, but would need to retire early, which I did.  Much of the physician workforce is also on the verge of retirement.

      I could work, except that when I retired, I had to either pay a malpractice tail of $40,000 or promise that I would not practice medicine again (except for a governmental agency such as the VA).  I would work part-time, except that the malpractice insurance is the same for full-time and part-time work.  At that rate, all of the earnings would be going to pay for the malpractice insurance.  I would have to see at least 300 people on average per year just to pay for the insurance.

      •  My former family physician (2+ / 0-)
        Recommended by:
        ybruti, Savvy

        Who was the head of the national family physician organization had the same problem.  As a result of heart problems, he decided he wanted to work part time.  The insurance company actually threatened to increased his malpractice rates as a result. He retired and his patients lost a brilliant and caring physician.

        If I am not for myself, then who will be for me? When I am only for myself, then what am "I"? And if not now, when?

        by betorah on Tue Feb 18, 2014 at 07:53:53 PM PST

        [ Parent ]

  •  Finally, financial necessity and scarcity are (13+ / 0-)

    forcing health care to think outside the box. The cries of not enough primary doctors has been countered by a growing appreciation of the work of Nurse Practitioners and Physician Assistants. A long-known statistic is that over 75% of patients sitting in a doctor's office can professionally be treated by a NP or PA. The list of common ailments that these midlevel  medical professionals can handle has long been established. Along with their medical training, NP's and PA's are schooled in what point a physician has to be called in.

    The benefits of using NP's and PA's are clear-cut: relieving medical problems in a timely fashion and, of course, reducing the huge cost of healthcare. With the use of midlevel medical professionals so obvious, the question arises as to why there isn't a similar group available in the dental profession.

    A growing dental problem in Alaska forced the dentists there to admit trained, midlevel dental professionals to perform fillings and simple extractions, all under the supervision of a dentist. The program was eminently successful but can't be replicated in the lower 48 states because of the tight grasp dentists hold on their wallets.  

    •  Not quite true (1+ / 0-)
      Recommended by:
      Catte Nappe

      The dentist I go to (in GA) has a separate hygienist, and about 4-5 dental assistants who do much of the prep work and some simple procedures, leaving the dentist more freely available for the hard stuff.

      As a result, they have a larger patient base and much cheaper rates than a lot of their 1 dentist, one DA, 1 clerical worker competitors.

      The Cake is a lie. In Pie there is Truth. ~ Fordmandalay

      by catwho on Tue Feb 18, 2014 at 11:32:24 AM PST

      [ Parent ]

      •  True enough (2+ / 0-)
        Recommended by:
        soarbird, Kevskos

        The prep work and simple procedures that you refer to do not encompass such dental work as fillings or extractions. I know this because the special interest laws paid for dentists would make it illegal for the dental hygienists and assistants to perform these procedures.

        The dental profession was taken great pains to prevent midlevel dental professionals from providing such important dental care - to the detriment of the American public.

  •  We have 2.4 doctors per 1,000 people (2+ / 0-)
    Recommended by:
    Catte Nappe, ybruti

    Not the best (by far) but not the worst.

    http://kff.org/...

    http://data.worldbank.org/...

    Daily Kos an oasis of truth. Truth that leads to action.

    by Shockwave on Tue Feb 18, 2014 at 11:22:36 AM PST

  •  80% of work done by doctors is projected to (1+ / 0-)
    Recommended by:
    frosti

    be done (or at least be doable) by machines (computers, etc) in a few years.

    So this is not a real problem - in fact the opposite might be.

    Similar to the current diminished demand for lawyers

  •  I got DR appts w/in days after 1/1. (4+ / 0-)

    A few days after ACA coverage kicked in 1/1 I called Kaiser  to get a general appt., thinking none would be available for at least a month.  Was shocked when said they had several times available that week.
      Then after seeing that DR, they referred me to a dermatologist for skin cancer check.  Again I thought it would be > month's wait, but had a choice of times for the next day!  That's astounding considering other HMOs have made me wait > 3 months to see a Derm.
      So much for any DR "shortage" in my area.

    My Karma just ran over your Dogma

    by FoundingFatherDAR on Tue Feb 18, 2014 at 11:45:53 AM PST

    •  We too have always had immediate access to (1+ / 0-)
      Recommended by:
      Kevskos

      very competent doctors at Kaiser. I particularly like the opportunity to use email to communicate with any of the doctors we have seen at Kaiser. Medicare wastes his time, though, by demanding he sees his patients at least once a year. We have a nice chat, but certainly a nurse could have taken the doctor's place for that.

      The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

      by ybruti on Tue Feb 18, 2014 at 01:38:34 PM PST

      [ Parent ]

  •  Very informative, thanks for your (1+ / 0-)
    Recommended by:
    ybruti

    hard work. This helps fill in the gaps in my knowledge of what the ACA does.

    I can't help it. I love the state of Texas. It's a harmless perversion. - Molly Ivins

    by rsmpdx on Tue Feb 18, 2014 at 12:03:58 PM PST

    •  Thank you! The subject was very interesting, (1+ / 0-)
      Recommended by:
      rsmpdx

      and google helped me locate some useful articles and websites. Masses of information, actually.  I had read John McDonough's book Inside National Health Reform, so I had some previous acquaintance with the subject. It's a great book telling how so many experts with decades of experience managed to put the ACA together with the help of determined political leadership.

      The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

      by ybruti on Tue Feb 18, 2014 at 01:45:06 PM PST

      [ Parent ]

      •  "experts with experience" (0+ / 0-)

        Were there a good number of medical experts? Doctors in private practice with experience?

        Because the resulting ACA doesn't reflect that.

        Too bad someone like Howard Dean, a doctor who as governor instituted a healthcare system in VT, wasn't put in charge of drafting the legislation, instead of Max Baucus, who represented the corporate interests.

        •  According to John McDonough (0+ / 0-)

          there were a lot of experts working on the ACA. Have you read Inside National Health Reform?

          The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

          by ybruti on Wed Feb 19, 2014 at 09:36:11 PM PST

          [ Parent ]

        •  You prefer to repeat the dogma (1+ / 0-)
          Recommended by:
          ybruti

          instead of learning some facts.

          Baucus's group worked on the financial aspects of the bill. Most of it was put together by a team including a number of doctors. The biggest part came out of the other Senate committee, the one that had been Kennedy's who had been working on healthcare for years.

          Doctors in private practice have only a small window on the whole health care system. They are not necessarily even interested in systems integration which is what the bill called for.

          I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

          by samddobermann on Thu Feb 20, 2014 at 12:12:24 AM PST

          [ Parent ]

          •  My own take (0+ / 0-)

            If a person looks at an issue, and makes up their own mind, they are not repeating dogma.  

            I worked for, and hoped for, a different result.  The ACA has its good points, but there are worrisome aspects to it. I also believe that the administration sold itself short--the timing was ripe for a bill that was real reform.  To me, that means quality care at a fair price.  The health insurance industry intrudes too much on this bill.

            Please share what your creds are, samddobermann.

  •  Primary Care - Exactly (1+ / 0-)
    Recommended by:
    ybruti

    That is what a well-balanced health care system should look like; a large cadre of primary care providers, well trained in diagnostics, prevention, and counseling, with a fraction of that number as specialists and surgeons and their personnell.

    And, perhaps we need to get sane and recognize that full-out medical care is needless and a waste for terminal conditions.  Yes, many more than in the past accept that palliative care alone is sufficient, but for the large number of science-denying reptilian-brain-thinking Americans, it is going to be a shock that they aren't going to get million dollar treatment while dying.

  •  Medicare funds Residency Programs (1+ / 0-)
    Recommended by:
    ybruti

    Medicare at least partially funds EVERY single accredited residency program in the USA.

    If the GOPers are so worried about a shortage of MDs then surely they are OK with increasing federal funding of residency programs, right? Oh wait, that would be (more) socialism and the GOP doesn't really care--this is just more grandstanding.

    From the Wikipedia page:

    Financing residency programs

    The Department of Health and Human Services, primarily Medicare, funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education or DME payments. Medicare also uses taxes for Indirect Medical Education or IME payments, a subsidy paid to teaching hospitals that is tied to admissions of Medicare patients in exchange for training resident physicians in certain selected specialties.[19] Overall funding levels, however, have remained frozen over the last ten years, creating a bottleneck in the training of new physicians in the US, according to the AMA

    •  Yes, this is why I always accepted anybody (2+ / 0-)
      Recommended by:
      ybruti, Savvy

      in my practice.  I knew that the state and federal government largely funded my education.  Of course, I did over time, get a larger and larger proportion of Medicaid/Medicare patients, who often have more complex, chronic illnesses.

      •  But part of the reason the Medicaid/Medicare (4+ / 0-)

        patients have more chronic and complex illnesses is because they're
        1) old
        2) poor
        3) disabled in some way (or multiple ways)
        4) didn't have regular care before

        Pick any combination.

        It's almost a given that anybody on Medicaid/Medicare, until the ACA, would either be very poor or old, or both, and if you're that poor often it's because you're physically or mentally unable to work.

        Often, the reason you can't work (or can't keep working) is because you're sick. Sometimes very sick.

        And sick people obviously need more, and more regular, care.

    •  There is already of surplus of residency positions (1+ / 0-)
      Recommended by:
      ybruti

      ...for primary care.  They go unfilled every year.

      The problem is not on the residency side- it is on the limited number of medical school positions.  There are a ton of qualified applicants who are rejected every year because there just aren't enough spaces.

      There is no lack of students applying to study for medical school.

      •  11 new medical schools have opened (1+ / 0-)
        Recommended by:
        ybruti

        in the last 10 year and more are coming on line now.

        Some who can't get in US schools go take their med school in foreign countries then do a residency here in the US.

        I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

        by samddobermann on Thu Feb 20, 2014 at 12:16:55 AM PST

        [ Parent ]

  •  I'd call that job creation. (1+ / 0-)
    Recommended by:
    ybruti

    And GOOD jobs, too.  Doctors, nurses, etc.   If they're needed, they'll show up.

    "Glenn Beck ends up looking like a fat, stupid child. His face should be wearing a chef's hat on the side of a box of eclairs. " - Doug Stanhope

    by Front Toward Enemy on Tue Feb 18, 2014 at 01:20:58 PM PST

    •  Inelastic supply (3+ / 0-)

      The problem is the lag time for creating those new nurses and doctors.  An MD is 8 years post-baccalaureate.  An advanced practice nurse is 3 years post-baccalaureate (although one of those is in full-time clinical practice as an RN).  The buy-in for the prospective MD or NP can be staggering: med school and nursing school are expensive, even if you go the state route.  It's not unheard-of for newly minted MDs to owe $500,000 in student loans, including for their undergraduate education.  Scholarships help but don't defray all expenses, and not everyone gets a scholarship.  Yes, these are good-paying jobs, but that's a hell of a debt mountain to ask a body to climb, while they're also trying to start their life-lives.

      "Education is the key to unlock the golden door of freedom." -- G.W.Carver

      by northbronx on Tue Feb 18, 2014 at 02:20:00 PM PST

      [ Parent ]

      •  There's also the constraints on supply (3+ / 0-)

        The system of becoming a doctor in the us is artificially slow, cumbersome, and complex, to the point of actually telling students what sort of doctor they can be if they want to do residency/practice in a particular area.

        It's utterly bizarre, guild-system-esque, needlessly prohibitively and living in a medical town I can honestly say there are a ton of doctors in my limited experience who would jump for joy on the plunger to give the AMA, and the other organization who's acronym escapes me, a lethal dose of morphine.

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

        by somewierdguy on Tue Feb 18, 2014 at 08:05:07 PM PST

        [ Parent ]

        •  AMA doesn't control things. The (1+ / 0-)
          Recommended by:
          ybruti

          US government funds residencies.   Limits were set by the Repub House when Gingrich "fixed" health care.  During residency doctors are paid $40k - $50k a year — and are already treating patients.

          Some of that $500k is unnecessary expenditures as med students and residents feel entitled to live very well as students.

          I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

          by samddobermann on Thu Feb 20, 2014 at 12:24:42 AM PST

          [ Parent ]

      •  There are plenty of med school applicants... (1+ / 0-)
        Recommended by:
        ybruti

        ...there just aren't enough positions for them to study.  And there is a higher net return on their investment than most graduate students.  The cost of the education to the student is not the limiting factor- it is the lack of positions available at med schools for them to study.

  •  making public med schools free (4+ / 0-)

    (as with all public university tuition) would remove a big barrier to more people becoming doctors and nurses and technicians. granted, the lower pay that increased supply would produce would remove an incentive for those who go into medicine to strike it rich, but we honestly don't need those people that much anyways.

  •  the cistern is rigged. System. Whatever. (1+ / 0-)
    Recommended by:
    wintergreen8694

    By creating such a rarified, god-like worship of the Merican Medicle Cystern, the AMA has managed to require huge sums of money just to get a license to practice.

    (law skules are close, but luckily, we ain't there yet)

    The net result is every student incurs great debt, unless subsidized by mommy or daddums doctor. That forces them into extremely rarified specialties that pay well, but serve the local community (NOT). That only makes the stress on the cistern even worse, because of a lack of reasonable family docs, ER docs, or those willing to deal with run of the mill problems.

    It is no surprise that this corrupt and self-defeating system leads to people seeking care outside of normal medical providers.

    If we had more doctors, more people would have access to medical care. If we forced medical schools to start admitting 2x the number of students, at 1/2 the price, everyone benefits. But logic and modern medicine seem to be at odd with each other.

    What we call god is merely a living creature with superior technology & understanding. If their fragile egos demand prayer, they lose that superiority.

    by agnostic on Tue Feb 18, 2014 at 03:26:57 PM PST

    •  the bulk of physicians graduate from public... (1+ / 0-)
      Recommended by:
      ybruti

      ...medical schools (funded by states).  You can't simply force them to admit students without providing more public funding.  Besides the fact that the reasonable maximum size for a medical student class is around 250- so they really just can't be forced to admit more students without serious amounts a new funding for larger student bodies and probably more state medical schools.

      I am all in favor of that additional investment- but we hear absolutely none of that from politicians and health experts.  In fact, most states are cutting back on funding and some are reducing medical class size.

  •  Cuba has a ton of doctors, maybe we could (3+ / 0-)

    borrow some for a bit.

    That, in its essence, is fascism--ownership of government by an individual, by a group, or by any other controlling private power. -- Franklin D. Roosevelt --

    by enhydra lutris on Tue Feb 18, 2014 at 04:23:47 PM PST

  •  3. more medical personnel education in US (which (0+ / 0-)

    is the perfect solution, along with non-medical eldercare, to chronically declining demand for employment in many industries).

    2. accept more emigrant nurses from Philippines (see: http://www.bbc.co.uk/...)

    1. accept immigrant doctors from Cuba. (see: http://translatingcuba.com/...)

  •  There are a lot of problems (1+ / 0-)
    Recommended by:
    ybruti

    with the US medical system. Part of the problem of the shortage of primary care physicians, is due to the AMA et al which has setup an almost guild like system. Only so many people can study to be doctors, only so many of a particular type of dr in an area. You want to be a urologist in Cookeville, TN? Tough, there are already 5. You can be an anesthesiologist.  Add to that the expense of the schooling, the difficulty getting into it, the difficulty getting residency, and boom, shortage of doctors leading to an enormous increase in the pay levels.

    Increasing the number of doctors is only part of it though, as others have said, most of the stuff you go in for doesn't require a doctor. A diagnostician would probably be the best first stop, nurse practitioners could do the low level stuff and anything complex or non-routine could be done by the actual doctors.
    Similar to what some of those countries with more doctors do..ya know..division of labor..

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

    by somewierdguy on Tue Feb 18, 2014 at 07:59:20 PM PST

    •  That's, um... (2+ / 0-)
      Recommended by:
      ybruti, samddobermann

      ...not even a little bit true (the dictating what specialty you can go into part, at least). There can be not enough of a market for 6 urologists in Cookeville, or the market may be controlled by a hospital that does not want to hire a urologist, but there is no control other than market forces. Plus, there is a 4-6 year lag time for the urologist/anesthesiologist between choosing a specialty and completing residency - at which point the market in Cookeville may be totally different. (incidentally, this is coming from someone who is very familiar with urology, anesthesiology, and ironically enough, Cookeville).

      Nobody wants to do primary care because, for most of us, it is boring and frustrating. You are a jack of all trades and master of none. You spend a lot of your day telling people that they have a cold and will not be getting antibiotics, which makes the patient mad at you. You feel impotent, because the most effective treatment for most of the patients you see is to advise them to lose weight, eat more healthfully, stop smoking, and/or take the medicines that you prescribed. It's understandably hard for the patients to do that, so you are just spinning your wheels.

      I just spent a day volunteering in a federally qualified health center clinic (in this case, basically indigent care). The only fulfilling part was that the clinic was slow, so I got to really talk to most of my patients. Unfortunately, those conversations really drove home just how powerless I am.

  •  Technology (0+ / 0-)

    Tech will eventually be the answer. Doctors and surgeons will eventually be replaced. A generation from now folks will be stunned to learn that we used to allow actual humans to do surgery.

    http://www.forbes.com/...

  •  Tax the specialists to fund a stipend for GP's (0+ / 0-)

    The disincentive for GP over specialist is the extra money you make, well, that's easy to fix.

    Think of it as the equivalent to a "Carbon Tax".

    And/or make it a requirement of your medical license to put in some % of you time as a GP, either X years of service or X% of your monthly time.

    Being a licensed medical doctor is not a right, it is a privilege. ;)

  •  Time and Money (2+ / 0-)
    Recommended by:
    ybruti, wintergreen8694

    are two large factors of why there's a so-called "doctor shortage."

    From a time perspective, medical school is typically four years post bachelors (which in and of itself takes a minimum of four years).  After graduation, these fledgling physicians must spend another three to seven years in residency, depending on what they choose to specialize in before they can practice medicine on their own.  Someone interested in becoming a doctor is looking at a minimum of an 11 year commitment, so even a focused 18-year-old college freshman who was determined to be a doctor from day one wouldn’t be finished until he or she was at least 29.  

    In reality, that journey usually takes much longer.  Bachelor’s degrees are frequently taking longer than four years to complete, especially when pre-med students are trying to juggle a demanding science course-load, find time to volunteer and/or work in the healthcare field (which if not mandatory for admission, is practically required in order to be a competitive candidate), and study for the MCAT, all while maintaining a high GPA.   Even after finishing undergraduate work, many students take a year or two before starting medical school to gain experience (sometimes taking additional coursework to find allied-healthcare jobs such as EMTS, CNAs, or Medical Assistants),  take a much needed break , or to improve their MCAT score.  The average age for starting medical school nationally is between 24-25 years old, which means that students won’t be finished until their early to mid-thirties. This isn’t even taking into consideration the growing number of non-traditional students who majored in something completely different, and find themselves going back to college to complete the necessary science and math prerequisites.  Meanwhile, their peers who graduated college and started working after have almost a ten-year head start on their careers and significantly less debt.

    Additionally, many important milestones typically happen in one’s twenties and early thirties.  While some people might be able to juggle planning a wedding and/or having a baby while going to school (and more power to them), for most it probably isn’t ideal or even feasible, at least not without significant family support.  This requires med-students, especially women, to make some difficult life-work balance decisions.  

    One solution to the shortage of primary care physicians might be to reduce or eliminate the mandatory residency requirement for general practitioners.  Pharmacists are not required to apply for residency positions post-graduation, yet they are respected as medication experts.  Medical school programs could be separated into two tracks, one for students who desire to become specialists (and go on to residency positions to further their training), and another for students who wish to become primary care physicians (which is the primary curriculum focus of most DO schools).  The healthcare needs of most individuals do not need to be addressed by highly specialized physicians, as evidenced by the growing demand for physician assistants and nurse practitioners.  It seems to me there should be something in between physician assistant/nurse practitioners who have a master’s degree and the current MDs in primary care who have typically three to four years of post-graduate residency.  One reason why pharmacy is highly lucrative for many students interested in medicine (and becoming increasingly saturated): it isn't nearly as much of a time sink when compared to becoming a physician (pharmacy school is three to four years post bachelors, and residency isn't required).

    •  You actually want primary care (1+ / 0-)
      Recommended by:
      ybruti

      doctors to be gifted diagnosticians. and a lot of medical schools will accept students with just 3 years of college.

      During residency they see and treat patients — and are paid salaries above the median of US salaries. It is not as arduous as you  make out.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Thu Feb 20, 2014 at 12:33:42 AM PST

      [ Parent ]

  •  Irony is (2+ / 0-)
    Recommended by:
    ybruti, wintergreen8694

    this headline:

    "But there aren't enough doctors!"
    coupled with this front page diary:
    Texas strips abortion provider's medical license over admitting privileges

    ''The guarding of military and diplomatic secrets at the expense of informed representative government provides no real security for our Republic.'' - Justice Hugo L. Black of the Supreme Court

    by geekydee on Wed Feb 19, 2014 at 03:43:27 AM PST

  •  Quality medical care--is that in the equation? (1+ / 0-)
    Recommended by:
    d

    "Doctor Shortage Could Ease As Obamacare Boosts Nurses, Physician Assistants".

    Excuse me, is that supposed to be good news?

    First of all, the headline is illogical.  Nurses and physician's assistants don't increase the number of doctors.  More doctors increase the number of doctors.

    Nurses and physician's assistants save time by doing certain medical services for patients.  Pharmacists do, too.  
    But will you admit that there are medical situations--starting with diagnosing and extending to brain surgery--that are the work of doctors?  We hope, good doctors.

    You are acting on behalf of insurers who simply don't want to pay doctors if they can wiggle out of it--doctor's fees may cut into their profit margin. They want to give more and more services to nurses and physician assistants, and they do not care if patients are ill-served by that.

    I wonder how attractive medicine will be for the best and brightest.

    By not eliminating the corporate profit interest (insurers and big pharma) from ACA by adopting Medicare for all or single-payer, the government has put its money and its citizens at the mercy of ...the insurers' profit margin.  Wake up.

    •  Actually it has been shown that (1+ / 0-)
      Recommended by:
      ybruti

      nurse practitioners are more adept at some things than doctors and can by taking over many time intensive but simple tasks enable the doctor to see more people and concentrate on the hard problems.

      In many countries a far larger proportion of childbirths are in the hands of nurse midwives. Their safety record is excellent and they know to refer in complex and difficult situations. They don't  push women into elective caesarians to the benefit of both mother and newborn.

      That is one way to decrease health care costs and thus the insurance costs.

      I don't think you realize that the "profit" that goes to doctors and hospitals are what keeps costs high.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Thu Feb 20, 2014 at 12:43:53 AM PST

      [ Parent ]

      •  Are you an administration apologist? (0+ / 0-)

        There you are again, sam dobermann.  Deflecting any constructive criticism.

        You say--"I don't think you realize that the "profit" that goes to doctors and hospitals are what keeps costs high."

        I see. First, the insurance industry takeover of doctors, making them their virtual and underpaid employees in the late 80s, early 90s has resulted in the large medical conglomerates we have today.  The reaction is a monster created by that greedy corporate industry.

        Second, earnings of the health industry, its CEOs, the spiraling costs of premiums, government subsidies of premiums--these are the profits that keep costs high.  Earnings of doctors and hospitals pale in comparison.

        What position do you have that lends your comments a spokesperson tone?  

        •  typo (0+ / 0-)

          Sorry--the above should read health INSURANCE industry--

          "Second, earnings of the health insurance industry, its CEOs, the spiraling costs of premiums, government subsidies of premiums..."

          •  You were correct in the first comment. (0+ / 0-)

            I don't know where you get the idea that insurers are taking over doctors. Cite please?

            First, the insurance industry takeover of doctors, making them their virtual and underpaid employees in the late 80s, early 90s has resulted in the large medical conglomerates we have today.
            Hospitals are hiring doctors or forming linked medical practices. Some hospital systems/chains have formed their own "in house" insurance branch but they are usually for their own facilities.

            I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

            by samddobermann on Sun Feb 23, 2014 at 05:24:58 PM PST

            [ Parent ]

            •  oh and I forgot to add there is much evidence (0+ / 0-)

              that those medical centers who employ their own doctors have lower costs and better safety records. I'm thinking of leaders like Mayo Clinics, Cleveland clinics, Intermountain Health.

              Doctors whose compensation depends on number of procedures do more even when unwarranted and even dangerous.

              Doctors can choose whether to become employees with the advantages of that or remain independent and assume all the risks that go with that.

              I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

              by samddobermann on Sun Feb 23, 2014 at 05:33:38 PM PST

              [ Parent ]

  •  "expand the scope of practice for... (0+ / 0-)

    ...  for nurse practitioners and physician assistants",such that it includes doing minor surgery & procedures like Hernia repair.

    •  really? (1+ / 0-)
      Recommended by:
      Eirene

      you do know they aren't trained in surgery, right?  You can't just expand their scopes without significant training.

      You might try advocating for the simpler approach of expanding the number of public medical schools.

  •  actually this is a real issue..and it's not new... (2+ / 0-)
    Recommended by:
    ybruti, Eirene

    ...the reason there aren't enough doctors is that the states have not been investing in educating more doctors.

    There are plenty of qualified students willing to study- but there really aren't any significant efforts to increase the number of students admitted to study- or start new state medical schools.  The states just do not want to spend the money.  Most states are actually cutting the funding to their medical schools.

    It is simple math, the population has increased significantly compared to the number of students that are allowed to enter (and therefore, graduate from) medical schools.  This has nothing to do with Obamacare- and was pretty much not addressed by the bill.

  •  A little basic arithmetic shows what a canard this (1+ / 0-)
    Recommended by:
    ybruti

    argument is. Prior to passage of the ACA, there were about 300 million insured Americans. The most rosy projection I've heard to date was that about 30 million previously uninsured will be added to the rolls of the insured. An increase of a measly 10 percent.

    What does that mean in real terms? It means for example my average 10 minute wait at the doctors office will increase by a whopping one whole minute to 11 minutes on average. Whoopdy do!

    "crush in its birth the aristocracy of our monied corporations which dare already to challenge our government" -Thomas Jefferson

    by Phil In Denver on Wed Feb 19, 2014 at 01:37:38 PM PST

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