When the government set out to help 32 million more Americans gain health insurance, Congress and the Obama administration acknowledged that steering more people into coverage had a dark underside: If it works, it will aggravate a shortage of family doctors, internists and other kinds of primary care.
So Page 519 of the sprawling 2010 law to overhaul the health-care system creates an influential commission to guide the country in matching the supply of health-care workers with the need. But in the eight months since its members were named, the commission has been unable to start any work.
The group cannot convene, converse or hire staff because $3 million that it needs for its initial year has been blocked by two partisan wars on Capitol Hill — strife over the federal budget and Republicans’ disdain for the health-care changes that Democrats muscled into law 14 months ago.
“We’ve been sort of hamstrung,” said Fitzhugh Mullan, a professor of medicine and health policy at George Washington University who is one of the 15 commission members appointed by the Government Accountability Office. The panel’s only activity so far, Mullan said, was a single conference call during which members were told they could not lobby members of Congress for funds or accept money to operate from foundations or anywhere else.
The National Health Care Workforce Commission is intended as an ongoing brain trust to focus new energy on solving an old problem that will become increasingly severe. The law says the new commission will analyze primary-care shortages and propose innovations for the government — and medical schools — to help produce the doctors and other health workers the nation needs. The idea is to furnish expertise to counterbalance the intense lobbying of medical groups.
The commission is unlike many other aspects of the law, which have built-in money to carry them out. Despite the efforts of some Democratic senators, appropriations for the commission were not in the continuing budget resolution Congress belatedly adopted for the fiscal year that began last fall. President Obama has requested the $3 million in his budget proposal for next year, but Republicans who control the House oppose it.
Having voted four months ago to repeal the entire Patient Protection and Affordable Care Act, as the law is called, the House GOP has proposed a budget that “makes the case ... no new taxpayer dollars will be directed to fund the law,” said Conor Sweeney, spokesman for House Budget Committee Chairman Paul Ryan (R-Wis.)
But Sen. Jeff Bingaman (D-N.M.), who has long advocated greater attention to the health-care workforce, said, “If, in fact, you are going to provide access to health care for all of these uninsured people, what is that going to do to the ability of our clinics and hospitals and doctors’ offices to handle this?” Even if the commission eventually is given the means to do its work, Bingaman said in an interview, “the delay is a serious problem.”
Proponents of the workforce commission say they were surprised that Republicans have balked, because there has, in the past, been little ideological schism over the need to bolster the supply of primary care — doctors, nurses, physicians assistants and others.
The law sets a goal of insuring the 32 million more Americans — divided between private health plans and an expansion of Medicaid — over about five years starting in 2014. The care they are likely to seek will translate into a need for about 10,000 more family doctors, general internists, pediatricians and geriatricians, according to a not-yet-published analysis for the Health and Human Services Department by the Robert Graham Center, a research organization devoted to primary care. The additional demand will exacerbate growing strains on the primary-care workforce caused by the growth and aging of the U.S. population.
“I think we are staring at a potential crisis,” said Sheldon M. Retchin, the commission’s vice chairman and the vice president for health sciences at Virginia Commonwealth University in Richmond. The costs, he said, are economic, along with patients’ ability to find care. Because more than half the nation’s health-care costs involve labor, Retchin said, shortages enable doctors to command higher pay, frustrating the goal of slowing health-care spending.
Medicaid, the public insurance program for the poor, faces a particularly severe problem, Retchin said, because even before the program expands in 2014, relatively few doctors are willing to accept adult patients on Medicaid in the program because the pay rates are so low in many states.
Such a collision between expanded insurance coverage and the limits of primary care has been evident vividly in Massachusetts. In 2006, it became the first state to compel most residents to carry health insurance — just as the federal law will do. In Boston,community health centers and the practices of primary-care doctors were deluged with more newly insured patients than they could handle. Since then, Massachusetts has fostered training of more such doctors. Even so, a new survey by the state’s medical society found that more than half of primary-care practices there are so full that they are closed to new patients.
Apart from the commission, the federal health-overhaul law includes several strategies to try to help ward off impending shortages. It expands the National Health Service Corps, a scholarship program for medical students to train for primary-care careers and work for a few years afterward in communities where doctors are scarce. The law also allows community health centers for the first time to be the main sites for residents in graduate medical training. And if any residency slots in medical specialties remain vacant, they now will be converted to primary-care residency positions.
Some health policy specialists predict those efforts won’t make enough difference. But Mary Wakefield, administrator of HHS’s Health Resources and Services Administration, said such provisions are “a really important tool to train, deploy and produce more primary care providers. Still, the commission “will play a very pivotal role,” she said.
“The workforce is needed to accomplish health reform,” said the commission’s chairman, Peter Buerhaus, director of Vanderbilt University Medical Center’s Center for Interdisciplinary Health Workforce Studies. “Now the clock is beginning to tick loudly.”