"As the American health care system has become more complex, specialized, and technical," says the official summary of the Clinton administration's health-care plan, "it has neglected some simpler and, ironically, less costly needs....If the American health care system is to provide high-quality care at affordable prices, it must strike a better balance between physicians, nurses, and other professionals who take care of basic needs and those who provide the most sophisticated and specialized treatment for serious illness."
To many health-care reformers, the need for "a better balance" is clear. About 30 percent of U.S. doctors are considered "general practitioners," while in some countries the percentage is almost 70 percent. In Canada, a single governmental organization controls the number of specialists trained. But most Americans still believe that patients acting as consumers, and medical students themselves, should have some say in the matter. Bill and Hillary Clinton have decided to guide medical education onto a more enlightened path. In reply to a question from a medical student worried about being forced into primary care, the First Lady told the annual meeting of the Association of Medical Colleges, "There will clearly still be opportunities to go into specialties and subspecialties. But you know, it's about time we start thinking about the common good and the national interest, instead of just individuals, in our country." If the Clintons have their way, the federal government will decide how medical students will be trained and what they will do when they graduate.
In all the hype over ClintonCare's more conspicuous components--employer mandates, new taxes, restrictions on patient choice, etc.--the plan's new rules regarding medical schools and teaching hospitals have received relatively little attention. Yet the attempt to achieve the "right" mix of specialists and general practitioners has far-reaching implications that go beyond the obvious limits on the freedom of medical students to shape their careers. It would threaten the economic viability of the nation's premier medical institutions and undermine the quality of health care without reducing costs over the long run.
Policy makers have for years been trying to change the mix of general practitioners and specialists in the belief that more preventive care will help control health-care costs. Several states have established financial incentives and funded G.P. residencies to encourage students to pursue primary care, particularly in rural areas. Bills have been passed in New York and New Jersey limiting the number and types of residency positions, and legislation almost passed in California that would have allocated half of all University of California positions to primary care. In 1992, the federal government began phasing in a new fee schedule for Medicare that cut payments to surgeons by between 8 percent and 14 percent while increasing payments to family practitioners by about 15 percent.
Under the Clinton administration's plan, within five years at least half of new U.S. physicians would be trained in primary care rather than specialty fields. Primary care, according to the administration, includes family medicine, general internal medicine, obstetrics/gynecology, and general pediatrics. During the five-year period, the plan would increase the number of primary-care residency positions in the nation's hospitals by 7 percent a year. The number of filled specialty training positions in which "excess supply exists" would drop by about 10 percent annually.
Each year, Secretary of Health and Human Services Donna Shalala would determine the number of training positions that should be available in each specialty. The secretary would appoint a National Council on Graduate Medical Education to advise her in this process. HHS would also appoint 10 regional councils, reporting directly to the department, to allocate residency slots to each teaching hospital.
The federal government would "encourage" hospitals and medical schools to go along with these rules by changing medical education funding. The plan would offer about $6 billion...