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New health reform scare: univeral coverage will cause a doctor shortage (I don’t buy it)

The newest fear mongering tactic of opponents to healthcare reform is that the US medical care system cannot handle the 15% to 20% increase in patient care load without blowing up and melting down into a confused jumble of waiting lists and general misery.

The idea is that there are just not enough medical doctors in the United States. A doctor shortage is a nice tactic since it focuses on scaring people who do have access to health care: things may be unpleasant and worrisome now for them, but with health care reform, they may be thrown into horrible waiting lists for just seeing a doctor.

One can see why people in the US might be susceptible to this tactic. Despite the fear mongering about waiting lists in other countries, it is more common to wait for primary care in the US than in several other countries with universal, or near universal, care.

In 2008, only about a quarter of survey respondents with chronic disease in the US said that they can see a primary provider on the same day in case of sickness or injury. This is a smaller proportion than in Australia, France, Germany, the Netherlands, New Zealand, and the UK (the UK!), and equal to that in Canada (Canada!). A larger proportion waited six days or more in the US than in any of these countries except Canada and Germany.(1)

Warning about a doctor shortage may be a nifty strategy to divide and conquer.

One answer to this scare tactic seems obvious: health care reform will free up spare doctor time currently spent on useless insurance paper work. The arithmetic sounds OK to me: We need to expand the population with health care by 15% to 20%, and seems like if the docs can spend 15% to 20% of their time on patient care rather than filling out forms, then we are set. It is more complicated than this because there may be a shortage of docs in certain areas with low rates of health insurance. Obama’s proposal to open community primary care clinics in underserved areas should help with this problem, but those doctors will have to come from someplace, which might worry some folks.

But I am a statistician and I like to see numbers, so I went looking for some kind of evidence that it universal could be done with a workforce comparable to that of the US. The handy dandy OECD health statistics data base (2) gives the most authoritative comparable statistics on the supply of practicing doctors, nurses, pharmacists and dentists in medium and high income countries.

Let’s start with doctors from 22 high income countries with data for 2006 or 2007. Three countries do not count their doctors the same way the other countries do (Ireland, the Netherlands, and Portugal), so I throw them out, leaving 19 countries. The number of doctors per 1000 people (the ‘density’) varies from a low of 2.09 for Japan to a high of 5.35 for Greece. The US ranks 16 out of these 19 countries, with 2.43 doctors per thousand people. Note that this is a relatively low number of doctors per thousand population compared to other high income countries despite the yelling about ‘Cadillac care’ one hears.

Anyway, are we sunk?

I don’t think so. Let us look at other high income countries with a density of doctors similar to that in the US:

MDs/1000, Country
2.81 Australia
2.48 UK
2.43 US
2.31 New Zealand
2.18 Canada
2.09 Japan

Looking at these other low doc countries should show what is possible with a low doctor density. Are they messes? IMHO, no. By most meaningful and comprehensive measures of the quality of care (I leave aside cherry picking one or two conditions) some of these countries perform better than the US.

How about taking life expectancy at birth, at 65 years; maternal, perinatal and infant mortality, potential years of life lost due to undelivered care for treatable illness (PYLL), and rate of improvement in PYLL. It turns out that Australia, New Zealand, Canada and Japan all beat the US on all those measures. (2) So, the bottom line is that good care can be delivered with a low density of doctors per capita.

It could be argued that people in the US are different, they may be lazy smoking drunken obese pigs, and the US cannot be treated like other countries. However, I think some of these countries with low doctor densities have risk profiles that are like the US not only now, but they have followed similar trends over the last 30 years.

Australia, New Zealand, and Canada have similar trends in the prevalence of male and female smoking, cigarettes consumed per smoker and alcohol consumption. A higher proportion of New Zealanders smoke, but they smoke less intensely; they drink more. Australia and New Zealand (and the UK) are following US trends in obesity, but with a lag of approximately ten years. Canadians are staying on the thin side. Except for skinny Canada, it looks like we descendents of the Brits all like the good life in all the ways that we can measure!

Bottom line is that I think if health care is delivered in an efficient manner, a country with a dubious health habits can receive good medical care at a doctor density comparable to that in the US. The US will have to increase the average efficiency of its doctors in terms of health outcome (for example, life expectancy) produced per physician. And studies have found that both Australia and New Zealand tend to have higher efficiencies for these kinds of health outcome. (3) So, there is no question that health care in the US must change for universal care to work, but IMHO, it has been done. Australia and New Zeland seem to have done it.

Using data for recent years, the US has a higher density of nurses (years 2005-2006), and about the same density of dentists (years 2003-2005) and pharmacists (years2003-2005) than Australia, Japan, New Zealand and Canada. So I do not see those professions as problems.

So, I am not buying the scare tactic of a catastrophic doctor shortage induced by health care reform.

I am also not worried if the US does need some more doctors, from my own personal experience talking with health educators. Many health professional schools have been asked to increase their annual number of graduates. They are quite willing and able (even eager), if only they could find the funds to pay the needed additional instructors and other resources. Actually, many clinical instructors are willing to do on the job teaching without pay (the intrepid and noble Faculty Without Salary), but it still costs money to provide resources so that they can do their jobs and teach effectively at the same time.

Health care interest groups, professional associations, and especially governments (and the socieity they serve) want more, but don’t seem to be willing or able to pay for it, which is a common tale these days.

I haven’t seen any numbers or arguments to support the doctor shortage scare tactic yet. Like most other health care reform scare tactics, I have heard isolated numbers taken out of context, and empty talk. But if anyone knows of an actual analysis, let me know, and I will consider it.

(1) Commonwealth Fund 2008, Commonwealth Fund International Health Policy Survey of Sicker Adults

(2) OECD Health data 2007 and 2009.,3343,en_2649_34631_12968734_1_1_1_37407,00.html
(you can get the extract for free with an excel file download here!),3343,en_2649_34631_2085200_1_1_1_1,00.html

(3) Zeynap Or, Jia Wang and Dean Jamison. International differences in the impact of doctors on health: a multilevel analysis of OECD countries. Journal of Health Economics 24 (2005) 531–560.

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