Senator Bernie Sanders, the Democratic Socialist from Vermont, is now chairman of the Senate Health, Education, Labor and Pensions (HELP) Committee. The HELP committee has more power than any other health committee in Congress. In a hearing that took place on Friday, February 17 the committee discussed the growing shortage of skilled workers in health care. Kaiser Health News reported on the hearing.
The shortage of health care workers of all sorts is a widespread problem, but is especially acute in rural areas and minority communities. Sanders pointed to the startling numbers of Americans living in medical care deserts to illustrate the point. There are nearly 100 million people who don’t have easy access to a primary care physician, almost 70 million with no dentist at hand, and some 158 million people who have few local mental health providers, Sanders said.
The Covid-19 pandemic caused many health care workers to experience burnout and many left the field or retired early. The work could be risky. According to Kaiser Health News 3,600 health care workers lost their lives due to Covid during the first year of the pandemic. Yet there was a shortage long before Covid.
“Despite all of our health care spending, we don’t have enough doctors, nurses, nurse practitioners, dentists, dental hygienists, pharmacists, mental health providers, and other medical professionals,” Sanders said, pointing to data that suggest the nation faces a shortfall of about 450,000 nurses and 120,000 doctors in the coming years, and 100,000 dentists now.
Sen. Sanders sees a lot of common ground and believes Republicans and Democrats alike can reach across the aisle and work together on solutions. However, that may be wishful thinking.
While Democrats and Republicans alike acknowledged the shortages hobbling care for hundreds of millions of Americans, any legislative solution must pass not only the Senate Health, Education, Labor and Pensions Committee, but also the full Senate and House of Representatives.
Members of the HELP committee are in agreement that something needs to be done. Yet, there is some level of disagreement about what has led to the shortfall in health care workers. Thus, the solutions will be vastly different depending on their respective viewpoints.
Members on both sides of the aisle recognized growing levels of burnout in the medical professions; increased threats faced by health care workers; the costs and challenges of working underserved areas; and financial incentives that steer younger professionals toward more lucrative specialties and higher-income areas.
Some solutions the senators agree on are simple things such as encouraging more low-cost options like community college and extending existing programs like the health care service corps that trains doctors for underserved areas. Yet, some ideas are not particularly relevant.
Sen. Mitt Romney (R-Utah) suggested the State Department should do a better job clearing foreign students and practitioners to immigrate here.
Sen. Tim Kaine (D-Va.) also raised the idea of unjamming the immigrant backlog.
The State Department can bring in all the foreign-educated medical graduates its wants but that will not boost the number of doctors trained each year. The United States already has more than 10,000 medical graduates who fail to match to a residency program every year. Many of those never match to residency and stop trying after several attempts. This is due to a shortage of residency slots. Medicare-funded residencies were capped in 1997 due to perceptions about a future physician surplus. Congress approved new Medicare-funded residency slots last year, but they’re limited to a paltry 200 a year for five years. That will only add 200 doctors a year the total trained. For that matter, physicians trained in recognized programs abroad, who have practiced for years, still must start over if they want to work in the U.S. All physicians are required to spend three to seven years in a residency program before they are allowed to practice, even if they were already trained elsewhere. That seems illogical. At the very least there should be an abbreviated program to test and refresh their clinical skills. Some other ideas:
Sen. Rand Paul (R-Ky.) said vaccine requirements were an impediment.
I like Rand Paul and I realize vaccines are controversial among some people, but I don’t think vaccines have anything to do with the number of people deciding on a career in medicine.
Sen. Roger Marshall (R-Kan.) raised regulations barring some surprise medical bills as harmful to doctors.
Seriously? Doctor Marshall is suggesting qualified people are abandoning their dream of practicing medicine because can’t balance bill patients? The vast majority of physicians have never balance billed patients. The No Surprises Act may alter which specialty a medical graduate pursues but I do not think it will alter whether someone goes to medical school. I have read that emergency medicine residency slots are less popular than in years past. However, the complaint was about private equity buying emergency medical staffing services and being the only employer, not the No Surprises Act.
Kaine, pointing in particular to the idea of expanding loan forgiveness for people willing to go into areas with shortages. “I think there’s great prospects for bipartisan progress on this.”
While this may sound reasonable, it’s ripe for abuse. It would take a bureaucracy to ensure people receiving loan forgiveness are in fact working in underserved areas. The rural county where I grew up subsidizes the health care workforce while they work in the area but there is no loan forgiveness. How many years would a new nursing graduate (when they are the last productive) have to work in a smaller town to forgive, say, $120,000 in student loans? Three years? Five years? Ten years? Would it take longer for someone with $120,000 in student loans than someone with $30,000? You get the picture.
This brings me to the question of the root causes for the health care workforce shortage.
1) Shortage of residencies. There are roughly 10,000 more people a year who have already graduated medical school but can’t get a residency slot. There are numerous ways to integrate these into the workforce. This includes more residencies and perhaps establishing another path to licensure.
2) Baby Boomers. Something like 78 million people fall into this group and they are transitioning from being doctors, nurses, physical therapists to retired patients themselves.
3) Barriers to entry. Nurse practitioners, pharmacists and physical therapist programs now require a doctorate. When I was first starting out working in a hospital those occupations required a bachelor of science degree. As the degrees became more lucrative, their respective governing bodies erected barriers making them much harder to obtain to keep competition down and salaries high.
4) Hospital consolidation. Hospitals are labor intensive. Nurses are a big cost. As hospitals consolidate in metro areas, they have more power to keep nursing salaries down (and other health care salaries). It is much easier to informally collude and pay lower wages when there are just three or four big health care systems in a major city and every hospital knows what the other is paying. When I was an accountant for a hospital, during a budget meeting a senior executive mentioned being called by a counterpart at a competing hospital complaining our hospital had raised nurses’ starting pay by roughly $100 a month. He asked if we were trying to ‘poach’ their nurses? He was insinuating a bidding war for nurses would not add any more nurses to the total in Dallas and would cost the hospitals a fortune.
5) High cost of medical education. College in general has risen in price and advanced programs can be even more expensive.
6) Burnout. Working for a hospital during Covid and being told to ‘suck it up’ when conditions got bad resulted in many nurses leaving and joining traveling nurse temp. agencies. Many doctors too got tired of the working conditions inside hospitals.
7) Health care workforce shortage. The shortage itself causes burnout. Workers are called on to work longer hours and care for more patients per hour.
8) Restrictive licensing. A nurse in Texas faces obstacles to working across the border in Louisiana or Oklahoma. In 2020 Hawaii waived licensing requirements for health care workers due to a severe shortage. In 2022 the state found itself on the verge of losing hundreds of nurses as the waiver was set to expire.
9) Educational bottlenecks. It is often the case that the people needed to teach the next generation of doctors, nurses, physical therapists, etc. find that the pay as university instructors is far less than they can earn working in their field. Thus, universities often have a hard time recruiting instructors.
Any other ideas? Let me know in the comments.