Correction Appended: Aug. 4, 2009
As the House and Senate prepare to embark on their summer recess without having passed any health-care-reform bills, President Obama's dreams of radically restructuring the system have, at least for now, bumped up against the reality of Washington politics. But even if Congress manages to overcome the many obstacles and pass some kind of meaningful reform this fall, the goal of covering some 50 million currently uninsured Americans will encounter a whole new range of hurdles. Chief among them is that there almost certainly won't be enough doctors to care for that many new patients.
Even without reform, experts on the health-care labor force estimate there is currently a 30% shortage in the ranks of primary-care physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, with the rest choosing more lucrative specialties. That could pose problems if a national health-care bill is enacted. After Massachusetts enacted mandates for universal health insurance in 2006, those with new coverage quickly overwhelmed the state's supply of primary-care doctors, driving up the time patients must wait to get routine appointments. It stands to reason that primary-care doctors could be similarly overwhelmed on a national scale.
But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat patients and diagnose ailments as well as prescribe medication. And they can do these things at a lower cost than doctors Medicare, for example, reimburses nurse practitioners 85% of what is paid to doctors for the same services.
The nurse-practitioner profession was created in 1965, the same year as the invention of Medicare, which dramatically increased the need for primary-care providers. Yet while nurse practitioners can be valuable assets in the context of health reform, they have also created a conflict with doctors, many of whom are not keen on being supplanted by providers with far less training; doctors in some cases have lobbied to restrict the services of nurse practitioners. "In some situations, it can be a turf battle," acknowledges Rebecca Patton, president of the American Nursing Association.
In addition to providing many of the same services less expensively, nurse practitioners offer something else that makes them darlings to health reformers: a focus on patient-centered care and preventive medicine. "We seem to be health care's best-kept secret," says Jan Towers, health-policy director for the Academy of Nurse Practitioners. Nurse practitioners may have less medical education than full-fledged doctors, but they have far more training in less measurable skills like bedside manner and counseling. "In the United States, we are so physician-centric in our health system," says Patton. "But it should be about wellness and prevention, not about procedures and disease management."
President Obama told the American Medical Association in May that the government should do "more to reward medical students who choose a career as a primary-care physician and who choose to work in underserved areas instead of a more lucrative path." As part of health reform, the Administration wants more money for the National Health Service Corps, which offers loan forgiveness to primary-care providers including nurse practitioners as well as doctors who agree to work in rural and remote areas. But even if these measures encourage more medical students to pursue careers in general practice, it will take years to have a real impact. Nurse practitioners, on the other hand, require fewer years of training and can therefore bump up their ranks faster.
In the recently released House health-reform bill, nurse practitioners (and physicians' assistants, another relatively new, but smaller, category of medical professionals who can perform medical procedures and often prescribe medication) are listed alongside doctors as primary-care providers. Nurse practitioners lobbied hard for this legislative language in meetings with White House health officials, including Nancy-Ann DeParle, Obama's health-reform czar. The nurse-practitioners lobby is hoping such federal recognition of the central role the profession can play in a revamped health system will exert pressure on states to ease restrictions. A patchwork of state laws now dictates how much freedom nurse practitioners have, ranging from states like Alabama, where nurse practitioners can work only under the supervision of a physician, to Oregon, where nurse practitioners are permitted to run their own private practices.
The original version of this article stated that Medicare reimburses nurse practitioners 80% of what is paid to doctors for the same services, when the correct figure is 85%. It also misidentified Jan Towers, health-policy director for the Academy of Nurse Practitioners, as Jan Powers.