The Hidden Health Crisis: America’s Physician Shortage is Slowly Worsening
Healthcare provider places bandaid on a patient after a vaccine. Photo by CDC.
A relatively unknown public health crisis is looming in the United States. By 2034, experts anticipate that the U.S. will be short at least 30,000, if not more than 100,000, physicians. This is a product of many factors: limited seats for medical school and residency, high cost of education, physician burnout, as well as aging physicians and patient populations.
The physician shortage is primarily affecting primary care visits in rural areas, leading to the establishment of medical deserts, areas in which residents lack access to pharmacies, primary care providers, and hospitals. A lack of access to healthcare in rural areas will have a detrimental impact on rural residents, leading to worse health outcomes over time than their urban counterparts. This will only serve to aggravate socioeconomic inequities, and this public health crisis must be addressed immediately.
Medical organizations, as well as lawmakers, are at odds over how to resolve this emergency. One solution includes expanding the scope of practice for nurse practitioners, but this has been met with pushback from lawmakers and physicians who claim that the scope expansion will authorize too much autonomy. Scope expansion for nurse practitioners will assist in curbing the effects of the physician shortage; however, it does nothing to address the underlying causes of why physicians are not practicing in rural areas and are leaving healthcare at an alarming rate.
The high cost of education is one of the most significant drivers of post-graduate pursuits and has contributed to the primary care doctor shortage and the creation of medical deserts. When the average doctor graduates from medical school, they are expected to take on more than $250,000 in debt. This often drives them to pursue higher-paying specialties over primary care in cities with higher salaries than in rural areas. This is illustrated by the 217 unfilled residency spots for family medicine in 2023, the most of any specialty. This has increased the primary care doctor shortage in rural areas, and now the classification of medical deserts can be ascribed to more than 80% of American counties.
About 20% of the American population lives in rural areas, but they are being served by less than 11% of the practicing physician population. This leads to a higher proportion of rural populations suffering from chronic conditions compared to their urban counterparts. Additionally, the residents of these medical deserts often face increased obstacles to care, including lack of insurance and lower income, which only exacerbates the healthcare disparities gap. As the crisis worsens, the physician-patient relationship will suffer due to decreased access to healthcare visits, insufficient time for visits, and lower quality healthcare overall.
What are possible solutions for this increasing public health crisis? The American Medical Association (AMA), which is widely considered the governing board of medicine in the United States, called for increased compensation for physicians, primarily from government insurance (like Medicaid and Medicare), the expansion of residency spots and easier immigration pathways for foreign doctors. The AMA’s solutions highlight the preeminent problems plaguing the profession today. Costs of managing medical practices have increased by 47% since 2001 to 2003. In contrast, physicians’ payments have decreased in that same time span, making it very difficult for many small, rural practices to stay operational. Additionally, residency spots are currently limited because they are decided through the Graduate Medical Education (GME) cap, a federal program that reimburses teaching hospitals for their residency training, which was proposed in 1996. It was only in 2022 that the GME cap added 1,200 more slots despite the fact that the population increased from 200 million to more than 300 million since the GME cap’s establishment. While the additional slots are a step in the right direction, they are long overdue, and at this rate, insufficient to meet the ever-growing demand for physicians.
Another potential solution is looking beyond physicians and toward nurse practitioners. Currently, the American Association of Nurse Practitioners (AANP) is lobbying Congress, citing arguments of nurses being more cost-effective than physicians and expanding nurse’s scope of practice from the current 27 states, to all of them.
While an increasing number of states are expanding the scope of practice for nurse practitioners in an effort to increase access to healthcare in rural areas, the AMA is actively fighting against these policy changes. Depending on the state, nurse practitioners are registered nurses who are able to diagnose patients and prescribe medication without physician oversight. A nurse practitioner’s education is more limited than a physician’s—six to eight years compared to a physician’s minimum of eight years before residency training. The debate around the efficacy of nurse practitioners as a stand-in for primary care doctors is multifaceted. Some papers report that patients found just as satisfactory care, if not more, with nurse practitioners compared to primary care doctors. Others report that nurse practitioners use more resources such as testing, leading to a more expensive bill, but achieve worse patient outcomes compared to physicians. The AMA, citing a nurse practitioner’s limited training experience compared to a physician’s, is firmly opposed to this scope expansion.
The current rate of residency expansion and Medicare pay cuts expands the scope of practice for nurse practitioners, and seems to be key to solving the physician shortage on the surface. However, it will only worsen the shortage in the long run because insurance companies may opt to only cover patients’ visits for nurse practitioners, since they are able to pay nurse practitioners less than a medical doctor. This would further disincentivize new physicians from practicing in rural areas. Expanding the scope of practice for nurse practitioners may curb the negative effects of the physician shortage, but it does nothing to address the root cause of the shortage, especially in rural areas lacking primary care. Congress and the AMA must work together to lower the barriers to entry for medical school and incentivize young doctors to take up primary care in rural areas through medical school scholarships or higher compensation.
A more sustainable solution involves advocating for improved compensation for primary care physicians. By addressing the financial disincentives that drive doctors away from primary care, the healthcare system can ensure the delivery of high-quality and cost-effective care. This approach not only resolves the patient outcome versus cost dilemma but also strengthens the foundation of the healthcare workforce, ultimately benefiting patients, providers, and the overall health system. H.R. 2474, also known as the Strengthening Medicare for Patients and Providers Act, is a bipartisan bill introduced in April 2023. This bill seeks to reconcile the amount of Medicare payments with the rising cost of inflation, ensuring that doctors are fairly compensated for their services, especially in rural areas. The bill would administer an annual physician Medicare payment update tied to inflation to practices, so they are able to continue providing the same services. This would prevent the closure of many private clinics and improve the patient-physician relationship because patients would not be forced to bounce around different physicians.
The question, however, should not be who is qualified to practice medicine, but how the decision-making process that selects future physicians is informed. Medicine, an ostensibly altruistic field, has become warped by economic motivators, to the point where many physicians report a feeling of helplessness when it comes to treating patients who cannot afford the exorbitant treatments. The medical school application process is tainted by similar flaws. Programs are interested in maintaining exclusivity, rather than admitting enough students to address the doctor shortage. The tools with which potential doctors are evaluated are inherently biased—look no further at the glaring lack of low-income students in medical schools. The median income of an incoming medical student’s parents in 2019 was $130,000 dollars, which is symptomatic of paradigms that have systematically corrupted the admission process. The answer does not lie in nurse practitioners versus physicians. As the nation grapples with the impending physician shortage, a comprehensive strategy that combines the strengths of both nurse practitioners and primary care physicians may offer a balanced and effective solution for ensuring accessible and quality healthcare for all. The simplest route to addressing our nation’s doctor shortage is a simple one: educate more doctors, and help them stay in a field that is dedicated to helping others.
Kristy Wang is a Staff Writer for the Columbia Political Review and a senior in Columbia College studying political science and biology. Kristy can be reached at kw2933@columbia.edu.