Part 2 of the Manpower Requirements for Healthcare Reform
By Dr. William Harvey, M.D.
In Part 1 of this post we looked at the Census reports on health insurance in the population and the Pew Hispanic Reports on Unauthorized Immigrants to create a range of the likely number of uninsured people (whether legal or not) in the US. We then applied those numbers to the current data on the healthcare workforce (from the Congressional Budget Office) to estimate how many additional healthcare professionals (HCPs) we would need to provide the same degree of medical coverage we provide currently to the insured population to the new “all American” population or the “universal” population.
In a nutshell, we need several hundred thousand additional physicians and nurses available as soon as any of these “expanded access” healthcare bills become effective. The reality is that we don’t have the infrastructure to deliver on any of the current pieces of legislation. In this post, I’ll try to estimate how quickly we could find or train the additional workforce and then look in detail at H.R. 3200, the only bill that addresses the issue, to see what the details of their workforce strategy would be.
Let’s start with physicians and use resources close to home. The American Association of Medical Colleges represents 131 US and 17 Canadian medical schools. There may be a few medical schools not part of AAMC, but for the most part this is the universe of likely local graduates. For the last 6 years (2002-2008), the total number of graduates has risen very slowly, from 15,676 (2002) to 16,167 (2008). Clearly we’re producing just enough physicians to replace physician retirees and not even close to providing the increase needed to handle newly insured individuals. Here is the AAMC projection of the gap between the number of physicians we need and the number we are likely to generate in our medical schools; note that this analysis was conducted before the 2008 elections and before the healthcare reform proposals were publicized. (Source: AAMC, Center for Workforce Studies. The Complexities of Physician Supply and Demand. Projections Through 2025. Available online.)
Can we increase the number of students in medical school? More data from the AAMC is particularly instructive here (see Table 7). The number of applicants has been a U-shaped curve for the period 1997-2008, while the number accepted and matriculating has remained relatively constant. What has apparently happened is that the attraction of medicine as a profession has gone down. Litigation has gone up, working conditions have gone down, Medicare payments have gone down, and the physician’s ability to practice medicine without the interference of the insurance and hospital bureaucracy has decreased. Compared to the freedom and compensation of the MBA track the medical track just isn’t worth it. If you want a depressing but enlightening experience, ask your primary care physician if he/she would recommend their profession to their child; the answer will often be eye-opening.
For nursing, the situation is even more critical. The Health Resources and Services Administration (HRSA) of the DHHS and the Bureau of the Census have been monitoring the US Nursing workforce for at least 20 years; the most recent report from the Division of Shortage Designation of HRSA – from 2007 – can be found here. The key issue (and result) is shown clearly in Figure 4 (see below): There has been a gap between supply and demand since at least 2000 and the size of the gap has grown and is expected to keep growing for at least the next 10 years. Looks very similar to the physician graph above, doesn’t it?
The situation for Licensed Practical Nurses (LPN) and Nursing Assistants is similar. In all cases, the number needed to replace retiring individuals and to provide care for the originally expected increment in insured population is being met not by internal training of local individuals, but rather by active immigration from low-income countries.
According to a 2007 publication from the University of Pennsylvania [Aiken LH. US nurse labor market dynamics are key to global nurse sufficiency. Health Serv Res. 2007 Jun; 42(3 Pt 2):1299-320], about 8% of RNs employed in the US were trained abroad. About 80% are from lower-income countries, meaning that the degree of immigration is very sensitive to the perceived income opportunities here. Immigration of nurses to the US has tripled since 1994, reaching about 15,000/year. Most of these nurses stay in urban areas; a small proportion are of Hispanic or black descent. The paper concludes that “increased reliance on immigration may adversely affect health care in lower-income countries without solving the U.S. shortage.” In short, we are creating a nursing “brain drain” from countries that need to retain their own educated trainees, while we are still not solving our own nursing shortage.
The trend in the US nursing pool is even more disheartening. As the HRSA report states:
- A growing shortage of RNs has been projected over the next 15 fifteen years, with a 12% shortage by 2010 and a 20% shortage by 2015 (Figure 4). The projected shortage is the result of the expected increase in demand coupled with a relatively stable supply of RNs.
- Figure 5 updates these projections based in part on the 2004 National Sample Survey of Registered Nurses (NSSRN). Total numbers of RNs may rise until 2016 if age-specific cohorts follow patterns observed in the NSSRN between 2000 and 2004. This is in large part because the sizes of birth cohorts in nursing tend to increase well into ages 50-55, and so a number of baby boomers (currently ages 43 to 60) may still enter nursing as a second career over the next 10 years.
- This does not mean that problems will not be felt until after 2016, however. Using these projections of numbers of RNs and projections of the total population and the population age 65 and older from the U.S. Census Bureau, Figure 5 shows that the number of RNs per 100,000 population will peak in 2012, while the number of RNs per 100,000 population age 65 and older will peak in 2008 and decline by 5% (falling below current rates) by 2012.
What does this mean for the current healthcare system? Again, the HRSA states that “a review of the literature revealed a number of studies examining future shortages of RNs relevant to this study.” Some of the key findings are summarized briefly below.
- Health care providers across a variety of settings reported increasing difficulty recruiting and retaining RNs, particularly in hospital settings.
- There were indications that the attrition from clinical settings may be related to dissatisfaction with working conditions. The 2004 NSSRN asked RNs about job satisfaction and found that 76% of RNs employed by hospitals and 75% of RNs employed by nursing homes were satisfied with their jobs, compared to 82% of RNs employed in nursing education and 83% of RNs employed in occupational health.
- There is growing concern about the impact of RN shortages on the quality of health care. A growing body of evidence demonstrates that hospitals with lower ratios of RNs to patients had more adverse events than hospitals with higher RN to patient ratios.”
How H.R. 3200 Addresses “The Workforce Issue”
To give credit where credit is due: H.R. 3200 recognizes that there needs to be a large increase in healthcare professionals. It solves this problem in a very direct fashion: by diverting the bulk of medical students, nursing students and public health students out of any freedom to direct their careers and lives and into proscribed government service. In section 2000 of the bill, a Public Health Investment Fund is created, funded with $88.7 billion over 10 years, in addition to funds allocated from the Prevention and Wellness Fund and a number of other funds identified in the bill.
A medical student or nursing student who needs financial assistance to complete their education will be offered a loan by the Federal Government. In exchange for this loan, the student will be required to join the National Health Service Corps and work off the loan at the rate of $50,000 per year. Since the typical medical student today has an average of $35,000 in pre-medical education debt and $141,000 in medical school debt (as well as $18,000 in other debt (car, living expenses, credit cards, etc.)) (source available online), this means the typical physician or nurse will serve in the government’s healthcare cadres for 4-5 years. Dental care and other primary care is included in this scheme (Section 2211 ff) as part of “Frontline Health Providers” Loan Repayment Program. The loans for these individuals, however, will be repaid by the Government at a rate not to exceed 50% of that paid for the National Health Service Corps “volunteers”.
The relevant sections for Nursing students start at Section 2221. For Nursing, the government repayment amount is pegged initially at $35,000 per year and increased for inflation thereafter. This part of the Bill is funded with a separate $1.45 billion over a 10 year period.
Section 340 adds the same structure for students interested in Public Health. The Bill also adds funding for Secretary DHHS to establish or fund additional programs for the training of Public Health professionals.
Subtitle D is titled “Adapting Workforce to Evolving Health System Needs”. Under this subtitle are sections dealing with “Health Professions Training for Diversity” (section 2242 ff). What is this? This isn’t medical training – it’s training in linguistic, cultural and “politically correct” behaviors, as the following quote shows:
“The Secretary shall establish a cultural and linguistic competency training program for health care professionals, including nurse professionals, consisting of awarding grants and contracts under subsection (b).
(b) Cultural and Linguistic Competency Training- The Secretary shall award grants and contracts to eligible entities–
(1) to test, develop, and evaluate models of cultural and linguistic competency training (including continuing education) for health professionals; and
(2) to implement cultural and linguistic competency training programs for health professionals developed under paragraph (1) or otherwise.
(d) Preference- In awarding grants and contracts under this section, the Secretary shall give preference to entities that have a demonstrated record of the following:
(1) Addressing, or partnering with an entity with experience addressing, the cultural and linguistic competency needs of the population to be served through the grant or contract.
(2) Addressing health disparities.
(3) Placing health professionals in regions experiencing significant changes in the cultural and linguistic demographics of populations, including communities along the United States-Mexico border.
(4) Carrying out activities described in subsection (b) with respect to more than one health profession discipline, specialty, or subspecialty.”
If our healthcare workforce barely has the time to learn the complexities of modern medicine, do they really need to spend time learning languages, Spanish-American and African-American history and the “cultural and linguistic demographics of populations, including communities along the United States-Mexico border”, i.e., providing healthcare preferentially to communities of “unapproved immigrants”? Why not Asian languages and history? Why not Native American languages and history? Why not Polish and German, working in the communities in Chicago and Milwaukee?
Part 3 of the Workforce portion of H.R. 3200 deals with Evaluation and Assessment of the Workforce Program (section 2261 ff). This starts with the creation by Secretary DHHS of yet another permanent group, the Advisory Committee on Healthcare Workforce Evaluation and Assessment. This group will enumerate healthcare workers and, within 2 years, “make recommendations on the supply, diversity and geographic distribution of the healthcare workforce”, as well as make “recommendations” regarding retention of the healthcare workforce, as well s make certain that the diversity, linguistic and cultural programs identified above are being executed. This Committee also has a significant role in the overall direction of healthcare education in the US (e.g., the number of specialty training slots) and of the distribution of medical resources generally (section 764).
Clearly, Part 3 should have been the most critical part of H.R. 3200’s workforce strategy. Bulking up medical and nursing school faculties is required before increased numbers of students can be admitted into those schools. If done properly, the process of creating the infrastructure will take several years. Yet, a higher priority is placed on the proper “indoctrination” of the workforce than on the creation of a proper infrastructure.
Another key issue is touched on in the question of “retention”. As the Federal Government learned in prior loan programs, when faced with the bureaucratic and unimaginative form of government medical practice, most volunteers “serve the time” needed to fulfill their obligations … and then get out to start their real lives and truly medical practice. Given the length of this repayment program and the likelihood that they will be assigned to geographically distant locations, most of the National Health Service Corps “volunteers” (or the Nursing Corps or other corps) will leave the Corps at the first opportunity.
Part 4 covers the actual details of Assessment of the Healthcare Workforce. As outlined here, this is the establishment of what would have been called “the state’s 5 year plan” for a centrally managed medical education system. As in the UK, the free choice of most healthcare professionals to choose their area of interest and to train in it, will be either eliminated or changed drastically to a later period in life.
Part 5 is more money allocated ($1.14 billion over 10 years) for Health Professions Training for Diversity and $1.15 billion more (over 10 years) for Interdisciplinary Training Programs, the Advisory Committee and Healthcare Workforce Assessment. After all, what’s a few billion more, here and there?
H.R. 3200 spends an inordinate amount of time addressing political and social correctness, while ignoring the critical needs to provide healthcare staffing for national needs and while creating a forced labor system for healthcare professionals. Coupled with the likely reduction in overall payments to healthcare professionals, consistent with the payment schema used for Medicare and Medicaid, we, the American people, are likely to find that:
- Academically qualified potential healthcare professionals will continue the trend of the last decade and avoid the healthcare professions;
- Current healthcare professionals will reduce their practice activities or take early retirement;
- Changes will be made in the required qualifications for healthcare professionals and expedited training will be provided to achieve the numbers needed to staff at least a minimal healthcare workforce;
- Specialist availability will disappear, as the system attempts to predict and produce specialists (a multi-year process) to meet geographic and population needs; and
- With no clear program to provide Quality; Access; and Internal Cost Containment, the system costs will continue to spiral and increased taxes will hit all strata of the American population.
The American people are correct in not trusting H.R. 3200 as the answer to our problems. Congress must understand the details of this bill and the implications of its social and political programming of the healthcare workforce, rather than focusing on the healthcare needs of the American people … and I use that last phrase very specifically – the emphasis on undocumented aliens in this bill is a kick in the teeth to anyone who is a citizen and/or pays taxes.
This Bill should have been “dead on arrival”. Is there a doctor in the house? We don’t need one to try and H.R. 3200. We just need one to call off “the code” and declare this thing DOA.
William Harvey is a physician with extensive experience in drug research and development. He began as an academic researcher but has been a pharmaceutical executive in the global development arena for almost two decades. His current position involves the strategic use of comparative effectiveness research to speed drug development and to educate healthcare stakeholders: government, payors, prescribers, and patients. He lives in the greater Philadelphia area.