By Leah Pierson
Recently, Derek Thompson pointed out in the Atlantic that the U.S. has adopted myriad policies that limit the supply of doctors despite the fact that there aren’t enough. And the maldistribution of physicians — with far too few pursuing primary care or working in rural areas — is arguably an even bigger problem.
The American Medical Association (AMA) bears substantial responsibility for the policies that led to physician shortages. Twenty years ago, the AMA lobbied for reducing the number of medical schools, capping federal funding for residencies, and cutting a quarter of all residency positions. Promoting these policies was a mistake, but an understandable one: the AMA believed an influential report that warned of an impending physician surplus. To its credit, in recent years, the AMA has largely reversed course. For instance, in 2019, the AMA urged Congress to remove the very caps on Medicare-funded residency slots it helped create.
But the AMA has held out in one important respect. It continues to lobby intensely against allowing other clinicians to perform tasks traditionally performed by physicians, commonly called “scope of practice” laws. Indeed, in 2020 and 2021, the AMA touted more advocacy efforts related to scope of practice that it did for any other issue — including COVID-19.
The AMA’s stated justification for its aggressive scope of practice lobbying is, roughly, that allowing patients to be cared for by providers with less than a decade of training compromises patient safety and increases health care costs. But while it may be reasonable for the AMA to lobby against some legislation expanding the scope of non-physicians, the AMA is currently playing whack-a-mole with these laws, fighting them as they come up, indiscriminately. This general approach isn’t well supported by data — the removal of scope-of-practice restrictions has not been linked to worse care — and undermines the AMA’s credibility.
The AMA’s own scope of practice website hardly bolsters its case. Under a heading that states “scope expansion does not equal expanding access to care,” the AMA claims only that “nonphysician providers (such as [nurse practitioners]) are more likely to practice in the same geographic locations as physicians” and “despite the rising number of [nurse practitioners] across the country, health care shortages still persist.” But unsurprisingly, both physicians and nurse practitioners (NPs) are more likely to be found in geographic locations with more people, although NPs do represent a larger share of the primary care workforce in rural areas..
Moreover, the AMA’s own Workforce Explorer tool suggests that NPs are playing a vital role in expanding access to care. For instance, this is a map of all the Family/General Practice physicians (blue dots), Internal Medicine physicians (yellow dots), and NPs (green dots) in Alaska, a state that does not restrict NPs’ scope of practice:
Clearly, NPs are practicing in many locations with few primary care physicians.
The AMA’s scope of practice lobbying is particularly frustrating because the Association could improve both the supply and allocation of physicians in a more evidence-based way: by reforming U.S. medical education. In other countries, physicians receive fewer years of training but provide comparable care. Instead of insisting that NPs and other clinicians get more training, the AMA should be working to make U.S. medical education more efficient by pushing for the creation of more three-year medical degrees, more combined undergraduate and medical school programs, and shorter pathways into highly needed specialties. The AMA could also make careers in primary care and rural areas more accessible by lobbying for more loan forgiveness programs, scholarships, and training opportunities for medical students interested in these paths.
Now is a pivotal time for the AMA to reconsider its aggressive scope of practice lobbying. Temporary regulations allowing NPs and other clinicians to do more during the COVID-19 pandemic could be evaluated and, if safe and cost-effective, expanded. At a time when the health care workforce is facing an unprecedented crisis, the AMA should fully atone for the workforce shortages it helped create.