Distributional Choices and Health Policy

Robert C. Bowman, M.D.

There have been 2 recent periods of time favorable to primary care in the United States. Most national leaders in medicine and medical education fought the managed care and health reforms just as they fought the creation of Medicare and Medicaid. It took many years to overcome the resistance. The efforts persisted for only a few years, but there were important lessons to learn. The learning may have been as temporary as the impact since rising health care costs are impacting more than just businesses. Some of the most devastating impacts involve state budgets where education has been replaced by health care. (Pew Center On the States) Education takes a double impact since school districts cut teachers to compensate for rising health costs. (2006 survey of school district budget officers)

There were also lessons to learn regarding the distribution of physicians. These are careers and locations listed in the 2005 Masterfile data for the 15400 – 15900 annual graduates of allopathic schools.

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The 1995 – 1997 graduating classes distributed throughout rural and lower income areas at the highest levels. The career choices of all types of students were impacted significantly, most importantly in the largest student groups with urban origins. The increased choice by urban students saturated urban and urban underserved and some rural positions. The increase in rural family physicians reversed previous declines in rural career choice.

For subsequent class years the primary care and rural careers have continued to decline. Family medicine choice has decreased by 50%. Because all of these careers depend upon family medicine choice, the indications are that the levels are lower than any shown above. With the decline in primary care numbers, the nation has lost the diversification of primary care. During this period primary care diversified into geriatric training and combined with rural communities, community health centers, behavioral training to meet specific workforce needs.

The 1990s period also acted as a natural experiment regarding the limitation of graduate medical education positions. This limitation was a critical part of increases in primary care, in family medicine, and in physician distribution. Unlimited graduate medical education facilitates subspecialty choice and major medical center practice.

The distributional results of the managed care and health reform era were outstanding. Distributional career choice increases involve far more than coincidence, involving both major periods of policy dominated by increased federal and state investments in lower and middle income populations. These investments also targeted the physicians and health care facilities most involved with such populations. Office based primary care in underserved areas peaked at levels not seen since the last great distributional policy period from 1965 – 1978. This earlier period involved the creation and growth of Medicare, of Medicaid, of family medicine, and of new medical schools and medical school positions. The doubling of class size during this period of primary care preference resulted in a near quadrupling of primary care graduates, real graduates who stayed in real office based primary care for decades. The year 1978 marked a peak year in internal medicine residency choice. (match data)

Because the health policies impacted family medicine and because family physicians concentrate outside of major medical centers, the policy changes impacted health access over many subsequent years. (Family Medicine Contributes Much More) The “Perfect Storm” of managed care was followed by the rebound factors and combines with the progressive losses of distributional types of students for several decades. (Changing Admissions) The policy changes tended to mask the progressive losses of distributional students. Primary care and family medicine choice did not suddenly collapse. The nation’s education systems and changes in medical school admission had already significantly changed the composition of the 16000 medical students. With over 3000 fewer distributional students graduating in 2004 compared to 1997, the nation faces increasing health access problems that will continue for some time. The nation better hope that it gets a good pitch to swing at as the count is 0 and 2. With 3 strikes you are out.

Physician Workforce Studies

Five Periods of Health Policy and Physician Career Choice

www.ruralmedicaleducation.org