I am a retired Geriatric Nurse Practitioner (DNP, GNP). One solution would be that all 50 states allow independent practice for advanced practice nurses (Nurse Practitioners, Nurse Midwives and Nurse Anesthetists). Slightly over half of the country allows full practice authority for NPs now. (https://www.aanp.org/advocacy/state/state-practice-environment) The AMA and AAFP are trade guilds that actively work against any legislation that consider such full practice authority in spite of the lack of evidence of inferior care by NPs and in spite of recommendations of the FTC and the NGA which support it. Interestingly enough many patients prefer seeing NPs and are usually unaware of exactly how the payment schemes (incident to billing) and regulations (so called supervision which is no "supervision" at all) are designed to line the pockets of the physicians rather than "improve" care. Similarly PAs which have even greater restrictions on their practice than NPs do should be allowed full practice authority. While this is not a total solution it would indeed go a long way to easing some of the problem. The onerous coding and documentation regulations are also part of the problem.
In my lifetime, I've had several PAs or NPs who were my primary care options and they were fantastic. They worked within a larger practice because of the lack of full practice authority but I never saw a "real doctor" when I was under a PA or NP's care. I love your idea and hope that it can come to fruition someday soon!
As one of the primary care physicians the article is referring to, the implication that any regulations on NPs are designed to "line the pockets of physicians" is incredibly offensive. Please be better than that.
Thank you for your contribution to care, but to say that supervision is lining physicians’ pockets I can assure you it is not. And if it is happening to some of your colleagues that they are being charged fees it is not a universal thing and I’m sorry they’re experiencing that.
I would add full practice authority for pharmacists to the list of providers who can support primary care. Pharmacists are doctorally trained and have over 2000 patient care hours when they graduate. We also need to remove regulatory restrictions for pharmacy support staff like pharmacy technicians. Pharmacy technicians can help decrease the administrative and medication dispensing workload to allow more pharmacists to support basic primary care. This solution would be increasingly meaningful in rural areas where access to any type of patient care is difficult.
Interestingly, the argument against single payer health insurance has long been “look at how long patients have to wait in Canada” and “do you want to have to wait 3 months for a specialist when you are told you have cancer”? Yet here we are, suffering the same thing WITHOUT the benefits of a single payer system. IMO this is what happens when you have capitalism in the driver’s seat of healthcare. No, it’s not an inherent evil to want to earn a living as a healthcare provider (be it as a Dr, NP, PA, RN…) but when profits and higher wages step in front of the actual patients (and this is particularly pointed at the insurance industry which is an albatross around our necks) NO ONE gets quality healthcare. Our healthcare system sucks! And there is no 1 reason for that. It’s a system built on profiting off of disease. The issues driving its dysfunction are multi faceted and will require groups to work together to address each one - from the insurance industry, their investors, the pharmaceutical industry and their investors, the physicians, the colleges who train them, the industry of student loans and their investors, ancillary staff, hospitals, and the patients who often disregard the things that WE can do to stay healthy vs adding another medication to our regimen - it will take ALL of us to accept responsibility for our part and a willingness to change before we will see progress on this issue.
People don’t want universal healthcare because of the wait times to receive care. Explain how paying thousands of dollars AND waiting for care is a better healthcare model?
I will use my sister as an example again. She lives in AU with a Medicare for all system. Last March she was diagnosed with squamous skin cancer. She called her preferred doctor and he did surgery on this within two weeks. Last May she began suffering with significant pain in her wrists- she is an expert outdoorswoman and has had serious injuries to both. She was given a nerve assessment within a month. She had surgery before the end of August- again with the surgeon she requested. A friend of mine here, in the U.S., had severe knee issues a year ago. It took her almost a year before she could find someone to do surgery on her knee. I don’t think we are doing well with wait times. We do pay a great deal more than just about every other democratic country.
This was an article I didn't know I needed! I have been on the merry-go-round for almost 6 years. When I think I've found a good Primary Care, they leave! I had no idea about the 1997 cap on doctor training. Now that I know, it makes so much sense. My local hospital is a training hospital for primary care and the physicians group associated with it is always flooded with residents that are in and out. It is a huge inconvenience, but now I know, it is crucial to have that in abundance.
Honestly, this article reminds me of the problems with education. Not enough teachers, not enough money, too much paperwork, too many students.
Can we make it a priority to care for the children, the sick, and the elderly please?
We also need to provide more scholarships for medical students. The debt burden is too high and will OF COURSE affect career choices—away from pediatrics and general medicine.
This is an excellent article! We absolutely need more physicians, especially in primary care. In the interim, PAs and NPs can help bridge the gap, but many of them are working in specialties, too, for the same reasons physicians are. While a PA or NP may not have the depth of knowledge as a physician, they can be a foot in the door to a practice, especially in specialties. When questions arise, they almost always can collaborate with a physician to ensure patients are getting the best care.
-Targeted GME Expansion: Increase Medicare-funded slots strategically—especially in: Primary care (family medicine, general internal medicine, pediatrics), Psychiatry, and Rural and medically underserved regions
-Tie new funding to workforce outcomes: Require hospitals receiving new slots to demonstrate community impact and retention.
-Public–Private Cost Sharing: Encourage state Medicaid programs, insurers, and large health systems to co-invest in training, not just Medicare.
My opinion: We need Congress to start functioning normally again (writing and passing legislation targeting the above). Unfortunately, we have a significant lack of leadership and courage right now.
You can create all the primary care residency slots you want, but if the goal is to get more primary care clinicians you have to improve working conditions as well.
1. Cost Containment: The main driver was budgetary discipline. By the mid-1990s, Medicare spending was climbing, and Congress sought to reduce federal healthcare expenditures as part of broader deficit reduction efforts. Teaching hospitals received billions annually for GME, and lawmakers feared unchecked growth in residency programs would further inflate Medicare costs.
2. Fear of Physician Oversupply: Policymakers and workforce analysts in the 1990s (e.g., the Council on Graduate Medical Education and the Pew Health Professions Commission) predicted a “physician surplus.” The assumption was that the U.S. was training too many doctors, which could drive up healthcare utilization and costs. Capping residency slots was seen as a way to stabilize the physician workforce and avoid unnecessary expansion.
3. Political Climate of Fiscal Conservatism: The mid-1990s saw a bipartisan consensus around balancing the federal budget (remember the Clinton–Gingrich negotiations). The BBA of 1997 aimed to achieve significant Medicare savings across the board, and GME funding was politically easier to freeze than to cut other benefits directly affecting seniors.
4. Lack of Workforce Coordination: There was no national planning mechanism linking the number of residency positions to public health needs (e.g., primary care shortages). Without that linkage, Congress preferred a freeze rather than expanding funding without a clear policy rationale.
Gina I have all the same questions but if I were to guess the answer is going to be money. Always is when it really should be about prioritizing people's care and basic needs
Gina, consider this. Supply and demand. Fewer doctors equals greater demand equals higher prices equals more money for doctors to make. Could this possibly be the reason?
The implication that this is all a behind-the-scenes scheme for doctors to make more money is offensive to the people that are sacrificing over a decade of their lives, along with all of the accompanying family time, etc, in order to become physicians.
Greg, I meant no offense to your profession and apologize for offending you, but we are not so naive to think that the profit motive of those in your profession is not being considered when they choose to become physicians and to game a system to their advantage would be preferable in some of their thinking ,in my opinion. My sense is that you are definitely not in that way of thinking and I applaud you for it. More scheming minds will find a way to make money in any endeavor because they are wired that way and need to be put in check as much as possible by governing bodies throughout our country to even the playing field for everyone else for no other reason than it is the right thing to do, i.e. fairness and equity is called for , especially, for the least of these .
It would behoove all of us to consider the Latin word "humanitas " to have a greater understanding of the human race and legislate accordingly . Our Founding Fathers understood it and came up with the Constitution , the Bill of Rights and the Declaration of Independence to help us form a more perfect union 250 years ago. We must never abandon the principles found in them and must continue to fight for there preservation and practice for the benefit of our progeny going forward.
Bottom line: I want for our health care system to be the best in the world , for everyone's benefit.
Fascinating! This shows the importance of quality nonpartisan journalism and investigative research. I had no idea of the root cause. It seems emblem of so many other dysfunctions causing the K-shaped economy.
Additionally, now we are further limiting access (both dollars and number of years) to borrow from student loan programs, making it even tougher for those that want to be physicians but can’t pay out of pocket for minimum eight years of schooling.
My father in law was a PCP and switched to the concierge model towards the end of his career. He said it gave him a lunch break for the first time in 25 years.
I've never had a PCP. Last time I needed to make an appointment, I selected "any available physician" and the wait was still 2 months for a 20 minute office visit. 😬 I live in a big city too, I can't imagine the access issues for people in rural areas!
I feel very lucky. I see three different Nurse Practitioners (Primary Care, Gynecology, and ENT) by choice. If any concerns arise, all are in practices with doctors who will see me or they can refer me to specialists. If there are Nurse Practitioners in your area, I recommend trying to get established with one.
Healthcare in the United States has so many problems and unfortunately lawmakers aren't doing anything to change policies. It's time to get rid of the politicians who can't seem to fix problems for the majority of the population in the USA.
I agree with everything in this article, but the issue isn't limited to MDs. My daughter is a DPT (doctor of physical therapy). Medicare doesn't fund any of their training, but they're running into many of the same issues.
She's been in the field, a lifelong dream career, full time for 3 years. She works in a hospital system, and she specializes in orthopedics and sports medicine. And she's already incredibly burnt out.
Insurance companies require billing 4 units per hour per clinician before they'll pay the hospital. Basically, that gives her 15 minutes/patient. If someone is coming in for their first post-op visit, they *need* more than 15 minutes with their DPT to gather history, discuss needs, and be taught initoal mobility movements. Ideally, that first post-op visit is an hour of 1:1 time. But no insurance company allows this.
As a result, she's often double-and triple-booked, which is exhausting in and of itself, but add on top of that guilt over not being able to give any of those patients her undivided attention. (And to my knowledge, she hasn't made a mistake, but one can easily see how this system amplifies the potential.)
She knows she'll end up going to a cash-pay-only practice in the next year or two. She's already started building a patient base at one on Saturdays. (So yes, she's now working 6 days/week to try to eventually bridge the gap between good patient care and not burning out completely.) She was opposed to this option for a long time because she knows it leaves out a significant portion of patients who need good care. But she also knows she'll work herself into a mental and physical health crisis in just a few years if she continues at the pace insurance companies require of the hospital systems. It's not sustainable, even at the fully staffed sports medicine clinic she works at.
So, the solution to this doctor dilemma in our country comes down to eliminating the 1997 cap toward the residencies of future doctors to allow for greater demand required to fill vacancies that currently exist and ,also ,to make sure that the projected incomes of primary care doctors are equal to that of specialists so there will be enough of both to be available to the patients needing them going forward. Congress needs to legislate these changes soon to forestall any future crisis in health care, for sure.
I hadvthe same set of doctors for 15 yrs, PCP and four specialists. I recently moved to Norfolk, VA. I am having a heck of a time finding a PCP. Without a PCP, I can schedule any of the specialists I need to see. I was hoping to get in before the end of the year because I've already met my medicare deductible for the year. But, I don't see that happening.
It's a shame that only the wealthy will be able to afford even seeing a doctor, much less paying for treatment and medication.
Anyone that has had to navigate their way through medical insurance companies knows the system is broke.
I am a retired Geriatric Nurse Practitioner (DNP, GNP). One solution would be that all 50 states allow independent practice for advanced practice nurses (Nurse Practitioners, Nurse Midwives and Nurse Anesthetists). Slightly over half of the country allows full practice authority for NPs now. (https://www.aanp.org/advocacy/state/state-practice-environment) The AMA and AAFP are trade guilds that actively work against any legislation that consider such full practice authority in spite of the lack of evidence of inferior care by NPs and in spite of recommendations of the FTC and the NGA which support it. Interestingly enough many patients prefer seeing NPs and are usually unaware of exactly how the payment schemes (incident to billing) and regulations (so called supervision which is no "supervision" at all) are designed to line the pockets of the physicians rather than "improve" care. Similarly PAs which have even greater restrictions on their practice than NPs do should be allowed full practice authority. While this is not a total solution it would indeed go a long way to easing some of the problem. The onerous coding and documentation regulations are also part of the problem.
In my lifetime, I've had several PAs or NPs who were my primary care options and they were fantastic. They worked within a larger practice because of the lack of full practice authority but I never saw a "real doctor" when I was under a PA or NP's care. I love your idea and hope that it can come to fruition someday soon!
As one of the primary care physicians the article is referring to, the implication that any regulations on NPs are designed to "line the pockets of physicians" is incredibly offensive. Please be better than that.
Incident to billing.
Thank you for your contribution to care, but to say that supervision is lining physicians’ pockets I can assure you it is not. And if it is happening to some of your colleagues that they are being charged fees it is not a universal thing and I’m sorry they’re experiencing that.
Incident to billing
I would add full practice authority for pharmacists to the list of providers who can support primary care. Pharmacists are doctorally trained and have over 2000 patient care hours when they graduate. We also need to remove regulatory restrictions for pharmacy support staff like pharmacy technicians. Pharmacy technicians can help decrease the administrative and medication dispensing workload to allow more pharmacists to support basic primary care. This solution would be increasingly meaningful in rural areas where access to any type of patient care is difficult.
Interestingly, the argument against single payer health insurance has long been “look at how long patients have to wait in Canada” and “do you want to have to wait 3 months for a specialist when you are told you have cancer”? Yet here we are, suffering the same thing WITHOUT the benefits of a single payer system. IMO this is what happens when you have capitalism in the driver’s seat of healthcare. No, it’s not an inherent evil to want to earn a living as a healthcare provider (be it as a Dr, NP, PA, RN…) but when profits and higher wages step in front of the actual patients (and this is particularly pointed at the insurance industry which is an albatross around our necks) NO ONE gets quality healthcare. Our healthcare system sucks! And there is no 1 reason for that. It’s a system built on profiting off of disease. The issues driving its dysfunction are multi faceted and will require groups to work together to address each one - from the insurance industry, their investors, the pharmaceutical industry and their investors, the physicians, the colleges who train them, the industry of student loans and their investors, ancillary staff, hospitals, and the patients who often disregard the things that WE can do to stay healthy vs adding another medication to our regimen - it will take ALL of us to accept responsibility for our part and a willingness to change before we will see progress on this issue.
I am a pediatrician and this is well said.
Well said, Tracey.
People don’t want universal healthcare because of the wait times to receive care. Explain how paying thousands of dollars AND waiting for care is a better healthcare model?
I will use my sister as an example again. She lives in AU with a Medicare for all system. Last March she was diagnosed with squamous skin cancer. She called her preferred doctor and he did surgery on this within two weeks. Last May she began suffering with significant pain in her wrists- she is an expert outdoorswoman and has had serious injuries to both. She was given a nerve assessment within a month. She had surgery before the end of August- again with the surgeon she requested. A friend of mine here, in the U.S., had severe knee issues a year ago. It took her almost a year before she could find someone to do surgery on her knee. I don’t think we are doing well with wait times. We do pay a great deal more than just about every other democratic country.
If you ever get a real answer to this, let me know. I have yet to receive one.
This was an article I didn't know I needed! I have been on the merry-go-round for almost 6 years. When I think I've found a good Primary Care, they leave! I had no idea about the 1997 cap on doctor training. Now that I know, it makes so much sense. My local hospital is a training hospital for primary care and the physicians group associated with it is always flooded with residents that are in and out. It is a huge inconvenience, but now I know, it is crucial to have that in abundance.
Honestly, this article reminds me of the problems with education. Not enough teachers, not enough money, too much paperwork, too many students.
Can we make it a priority to care for the children, the sick, and the elderly please?
We also need to provide more scholarships for medical students. The debt burden is too high and will OF COURSE affect career choices—away from pediatrics and general medicine.
This is an excellent article! We absolutely need more physicians, especially in primary care. In the interim, PAs and NPs can help bridge the gap, but many of them are working in specialties, too, for the same reasons physicians are. While a PA or NP may not have the depth of knowledge as a physician, they can be a foot in the door to a practice, especially in specialties. When questions arise, they almost always can collaborate with a physician to ensure patients are getting the best care.
Good point.
Thank you for stating the obvious problem, and what caused it. But what I REALLY want to know is WHY!
Why did congress cap funded residencies?
Who pushed for that?
WHY!?!
Why do we have caps at all? Are caps necessary? Why?
Why does Medicare discriminate against one specialty of doctors as opposed to another?
What is the rationale!?!
AI solutions to the current workforce shortage:
-Targeted GME Expansion: Increase Medicare-funded slots strategically—especially in: Primary care (family medicine, general internal medicine, pediatrics), Psychiatry, and Rural and medically underserved regions
-Tie new funding to workforce outcomes: Require hospitals receiving new slots to demonstrate community impact and retention.
-Public–Private Cost Sharing: Encourage state Medicaid programs, insurers, and large health systems to co-invest in training, not just Medicare.
My opinion: We need Congress to start functioning normally again (writing and passing legislation targeting the above). Unfortunately, we have a significant lack of leadership and courage right now.
You can create all the primary care residency slots you want, but if the goal is to get more primary care clinicians you have to improve working conditions as well.
The WHY on the cap per AI:
1. Cost Containment: The main driver was budgetary discipline. By the mid-1990s, Medicare spending was climbing, and Congress sought to reduce federal healthcare expenditures as part of broader deficit reduction efforts. Teaching hospitals received billions annually for GME, and lawmakers feared unchecked growth in residency programs would further inflate Medicare costs.
2. Fear of Physician Oversupply: Policymakers and workforce analysts in the 1990s (e.g., the Council on Graduate Medical Education and the Pew Health Professions Commission) predicted a “physician surplus.” The assumption was that the U.S. was training too many doctors, which could drive up healthcare utilization and costs. Capping residency slots was seen as a way to stabilize the physician workforce and avoid unnecessary expansion.
3. Political Climate of Fiscal Conservatism: The mid-1990s saw a bipartisan consensus around balancing the federal budget (remember the Clinton–Gingrich negotiations). The BBA of 1997 aimed to achieve significant Medicare savings across the board, and GME funding was politically easier to freeze than to cut other benefits directly affecting seniors.
4. Lack of Workforce Coordination: There was no national planning mechanism linking the number of residency positions to public health needs (e.g., primary care shortages). Without that linkage, Congress preferred a freeze rather than expanding funding without a clear policy rationale.
Gina I have all the same questions but if I were to guess the answer is going to be money. Always is when it really should be about prioritizing people's care and basic needs
Gina, consider this. Supply and demand. Fewer doctors equals greater demand equals higher prices equals more money for doctors to make. Could this possibly be the reason?
The implication that this is all a behind-the-scenes scheme for doctors to make more money is offensive to the people that are sacrificing over a decade of their lives, along with all of the accompanying family time, etc, in order to become physicians.
Greg, I meant no offense to your profession and apologize for offending you, but we are not so naive to think that the profit motive of those in your profession is not being considered when they choose to become physicians and to game a system to their advantage would be preferable in some of their thinking ,in my opinion. My sense is that you are definitely not in that way of thinking and I applaud you for it. More scheming minds will find a way to make money in any endeavor because they are wired that way and need to be put in check as much as possible by governing bodies throughout our country to even the playing field for everyone else for no other reason than it is the right thing to do, i.e. fairness and equity is called for , especially, for the least of these .
It would behoove all of us to consider the Latin word "humanitas " to have a greater understanding of the human race and legislate accordingly . Our Founding Fathers understood it and came up with the Constitution , the Bill of Rights and the Declaration of Independence to help us form a more perfect union 250 years ago. We must never abandon the principles found in them and must continue to fight for there preservation and practice for the benefit of our progeny going forward.
Bottom line: I want for our health care system to be the best in the world , for everyone's benefit.
Clark, And yet doctors are quitting?
Good point. Go figure.
Fascinating! This shows the importance of quality nonpartisan journalism and investigative research. I had no idea of the root cause. It seems emblem of so many other dysfunctions causing the K-shaped economy.
Additionally, now we are further limiting access (both dollars and number of years) to borrow from student loan programs, making it even tougher for those that want to be physicians but can’t pay out of pocket for minimum eight years of schooling.
My father in law was a PCP and switched to the concierge model towards the end of his career. He said it gave him a lunch break for the first time in 25 years.
I've never had a PCP. Last time I needed to make an appointment, I selected "any available physician" and the wait was still 2 months for a 20 minute office visit. 😬 I live in a big city too, I can't imagine the access issues for people in rural areas!
I feel very lucky. I see three different Nurse Practitioners (Primary Care, Gynecology, and ENT) by choice. If any concerns arise, all are in practices with doctors who will see me or they can refer me to specialists. If there are Nurse Practitioners in your area, I recommend trying to get established with one.
Healthcare in the United States has so many problems and unfortunately lawmakers aren't doing anything to change policies. It's time to get rid of the politicians who can't seem to fix problems for the majority of the population in the USA.
I agree with everything in this article, but the issue isn't limited to MDs. My daughter is a DPT (doctor of physical therapy). Medicare doesn't fund any of their training, but they're running into many of the same issues.
She's been in the field, a lifelong dream career, full time for 3 years. She works in a hospital system, and she specializes in orthopedics and sports medicine. And she's already incredibly burnt out.
Insurance companies require billing 4 units per hour per clinician before they'll pay the hospital. Basically, that gives her 15 minutes/patient. If someone is coming in for their first post-op visit, they *need* more than 15 minutes with their DPT to gather history, discuss needs, and be taught initoal mobility movements. Ideally, that first post-op visit is an hour of 1:1 time. But no insurance company allows this.
As a result, she's often double-and triple-booked, which is exhausting in and of itself, but add on top of that guilt over not being able to give any of those patients her undivided attention. (And to my knowledge, she hasn't made a mistake, but one can easily see how this system amplifies the potential.)
She knows she'll end up going to a cash-pay-only practice in the next year or two. She's already started building a patient base at one on Saturdays. (So yes, she's now working 6 days/week to try to eventually bridge the gap between good patient care and not burning out completely.) She was opposed to this option for a long time because she knows it leaves out a significant portion of patients who need good care. But she also knows she'll work herself into a mental and physical health crisis in just a few years if she continues at the pace insurance companies require of the hospital systems. It's not sustainable, even at the fully staffed sports medicine clinic she works at.
We should somehow make insurance companies pay for medical resident training and maybe even medical school training.
They make all the profits off of our care.
So, the solution to this doctor dilemma in our country comes down to eliminating the 1997 cap toward the residencies of future doctors to allow for greater demand required to fill vacancies that currently exist and ,also ,to make sure that the projected incomes of primary care doctors are equal to that of specialists so there will be enough of both to be available to the patients needing them going forward. Congress needs to legislate these changes soon to forestall any future crisis in health care, for sure.
I hadvthe same set of doctors for 15 yrs, PCP and four specialists. I recently moved to Norfolk, VA. I am having a heck of a time finding a PCP. Without a PCP, I can schedule any of the specialists I need to see. I was hoping to get in before the end of the year because I've already met my medicare deductible for the year. But, I don't see that happening.
It's a shame that only the wealthy will be able to afford even seeing a doctor, much less paying for treatment and medication.
Anyone that has had to navigate their way through medical insurance companies knows the system is broke.