This week's prize for gall goes to the American Medical Association, for its new report warning about a "surplus of physicians" in the United States. From 1965 to 1984 the number of doctors almost doubled, and the ratio of doctors to general population rose by half. Increases are expected to continue. The AMA warns that too many doctors "could lower the quality and raise the cost of physicians' services."
The doctors' real concern is different. Partly because of competitive pressure, their incomes have started to shrink. Don't panic: the average doctor still made $108,000 in 1984. But after inflation this was a 2 percent drop from the year before. You may think there's no law that says doctors' incomes, which doubled in real terms during the 1960s and 1970s, must never go down. But this is a complex matter, on which you should consult your doctor.
Dr. Arnold Relman, editor of the prestigious New England Journal of Medicine, explained to The New York Times: "All over the country, doctors are more concerned about their economic future than I can ever remember. There is more pressure on the doctor to maintain his income than is good for the public or the profession."
It is especially touching to hear this concern from Dr. Relman. This same Dr. Relman has led the campaign against commercial hospital chains. In a recent National Academy of Sciences report on for-profit hospitals, Princeton economics professor Uwe Reinhardt notes that the position of the medical establishment is that doctors should be independent, profit-maximizing entrepreneurs, while hospitals should be nonprofit, tax-subsidized charities.
According to a poll, only 12 percent of the general public thinks there are too many doctors, whereas almost half of all doctors think there are too many doctors. The AMA takes this as evidence that the public needs to be educated about the doctor surplus. I take it as human nature. In my opinion, there are too many columnists, and I would like to see drastic steps taken to reduce future entry into the profession.
Like all special pleaders for protection from competition, the AMA expresses its great love of the free market. But it argues that the free market works only "in an environment free of external regulation," and in the market for doctors, "Entry into the profession is largely controlled by policies set in the public sector." That's true. But the main effect of those policies is to restrict the number of doctors. Thousands of qualified people every year would like to become doctors, but can't get into medical school. The AMA just wants the squeeze to be even tighter.
It's also true that government policies over the past couple decades have enticed people into becoming doctors. These policies -- the comically misdesigned Medicare and Medicaid reimbursement systems -- have artificially inflated doctors' incomes. But lower pay is one way to reduce the supply of doctors that doctors emphatically reject.
Because of a justified fear of the antitrust laws, the AMA's proposals are written in a kind of code. The AMA should "take a more active stance." Medical schools should be "encouraged" to "establish appropriately total medical school enrollment." But the agenda is clear: fewer admissions to medical school.
The AMA's problem is that would-be doctors are evading this bottleneck by going to medical school abroad. It surely is insane for the United States to be sending many of its future doctors to Third World countries for their training. But the AMA's solution -- make it harder for foreign medical graduates to practice here -- is deeply hypocritical. In the context of a report about a supposed doctor surplus, the AMA's unctuous "concern . . . about the quality of training" at foreign medical schools stands revealed as a simple attempt to reduce the competition.
How, in defiance of all economic logic, can an increase in the supply of doctors lead to higher prices for medical care? The AMA notes correctly that this is precisely what has happened in the recent past. It also speculates that increased competition in certain specialties may drive specialists into general practice and, "Since specialists tend to charge more . . . the cost of primary care would increase."
This assumes that doctors can charge whatever they want and get away with it. To some extent, that's true. Has anyone ever price shopped for a coronary bypass? But recent income data suggest we may finally be reaching the point where doctors can no longer make up for fewer patients by charging more to each one. Meanwhile, the AMA has fought against every effort to introduce market forces into medicine, such as the growth of health maintenance organizations.
The AMA's chief function throughout its history has been to maintain doctors' incomes by restricting entry into the profession. I'm not going to worry about a surplus of doctors until I can see one without twiddling my thumbs in the waiting room for an hour.