Healthcare experts have warned of an impending physician shortage for decades, with many suggesting certain provisions of the ACA — including the individual mandate and Medicaid expansion — have exacerbated the problem. But is the U.S. really on the brink of a serious physician shortage?
Ezekiel Emanuel, MD, PhD, a professor and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania in Philadelphia, would say no.
The latest projection from the Association of American Medical Colleges, released in March, says the U.S. could face a physician shortage of between 40,800 to 104,900 physicians by 2030. Although the "ominous" projections of a physician shortage have already motivated significant reforms, they don't add up, according to a recently published article in JAMA by Dr. Emanuel and undergraduate students Emily Gudbranson and Aaron Glickman of the University of Pennsylvania.
In the article, Dr. Emanuel, Ms. Gudbranson and Mr. Glickman argue there is reason to reassess the data on whether a physician shortage really exists.
1. While the number of insured patients has increased under the ACA, so has the number of physicians. Some 22 million previously uninsured U.S. residents gained coverage through Medicaid expansion under the ACA, while the individual mandate incentivized many others who previously skipped out on coverage to purchase plans on the individual market. Meanwhile, the number of medical schools in the U.S. has increased from 125 to 145 over the last 15 years, according to the report. Medical school enrollment has increased 28 percent from 16,488 in 2002 to 21,030 in 2017, and the number of active residents currently enrolled in Accreditation Council for Graduate Medical Education programs has increased 7.9 percent from 115,293 to 123,409 during the same timeframe.
2. Wait times are not measurably longer since the advent of the ACA. Many patients and experts worried that the coverage expansions under the ACA would lead to longer wait times. A 2013 Commonwealth Fund survey cited by Dr. Emanuel and his colleagues found that 52 percent of adults could not get a same-day or next-day appointment with their physician.
However, long physician wait times existed before the ACA was enacted. In 2009, the average time to wait for an appointment with a family physician was 20 days. Today the average time is 19.5 days, according to the report. Data suggests wait times have also improved for Medicaid beneficiaries. A study of 295 primary care practices in Michigan found appointment availability for new Medicaid enrollees increased from 49 percent before the state expanded Medicaid to 55 percent after expansion.
3. The U.S. has enough physicians. Dr. Emanuel and his colleagues arrived at this conclusion from a simple calculation to estimate the number of physicians required to care for all U.S. residents.
The U.S. currently has more than 900,000 active physicians, including 441,735 primary care physicians, 80,000 pediatricians and 484,384 specialists. Of the total number of primary care physicians, about 12 percent work part time, leaving about 388,000 full-time primary care physicians.
The Agency for Healthcare Research and Quality recommends the average physician provide care to between 1,500 and 2,000 patients per year. A survey from the Medical Group Management Association found that the median physician panel size was 1,906 and the average was 2,184, according to the report. Dr. Emanuel reasoned that if each of the 388,000 full-time primary care physicians cares for an average of 1,500 patients, they could care for about 583 million people. There are 240 million adults currently living in the U.S. Similarly, if each of 49,000 pediatricians cared for 1,500 children, they could provide care for the 73 million U.S. children. By these calculations, there is a surplus, not a shortage, of physicians in the U.S.
Why does the AAMC forecast a physician shortage?
Given Dr. Emanuel's calculations, one might wonder where the projected physician shortage comes from. The AAMC predicts a shortage will occur because of three main reasons, according to the report: reduced physician work hours, upcoming physician retirements and an aging population.
The AAMC's projection report suggests that physicians under 35 years work 13 percent fewer hours per week than previous generations. But even if younger physicians work fewer hours, Dr. Emanuel says there are still enough physicians because the 388,000 full-time primary care physicians are more than enough to cover all patients in the U.S.
Although it is true that about one-third of all currently active physicians will reach the age of retirement within the next decade, Dr. Emanuel says most older U.S. adults are delaying retirement. Moreover, he argues that even if one-third of all current physicians retire, the approximately 260,000 remaining full-time primary care physicians would be enough to care for Americans.
Dr. Emanuel says the growing aging population is likely to increase volume of care, but there are more efficient ways to address their health needs than simply expanding the supply of physicians. Annual wellness checkups, follow-up appointments and support for medication adherence are all important aspects of maintaining health and can be administered by nurse practitioners, care coordinators and medical assistants.
For the full article and expanded commentary on the physician shortage projection, click here.