Jonathan Wolfson is the chief legal officer and policy director at the Cicero Institute. He led the Policy Office at the US Department of Labor and was an official at the Department of Housing and Urban Development. This transcript has been edited for length and clarity.
Federal Newswire: Your organization has focused on critical issues in healthcare. Does this include the shortage of physicians?
Wolfson: This is one of those challenges that is big, [and] it's getting bigger. The American Association of Medical Colleges now predicts that the physician shortage is going to be somewhere between 100,000 and 200,000 doctors by the middle of the 2030s.
By the end of this decade alone, most states in the country are going to be short about 500 or more primary care doctors…the pediatricians for kids, OBS, family practice, those are the practices that don't necessarily make as much money, and so people finish med school and they want to go become specialists.
As a free market guy, I have no problem with people deciding what they want to do. But as a country, it is becoming a big challenge. We've found ways to get people health insurance, but having health insurance doesn't mean you get health care. You can show up at a doctor's office and say, “I have health insurance.” The doctor says, “Congratulations, I'll see you in six months.” For most people, that doesn't seem like they have health care.
There's nothing simple about being a doctor. In the United States, you have to go to four years of college, you have to go to four years of medical school, and then you have to do three years of residency. We're talking about an 11-plus year process.
We feel like finding a way to get doctors who are trained, who are already touching patients somewhere else in the world, get them into the United States and be able to practice immediately really does start to solve the problem now rather than in 10-plus years.
Federal Newswire: What are the other roots of this shortage in healthcare?
Wolfson: Demand is definitely rising for health care services in the United States, and there are a lot of reasons. Providing more and more people access to health insurance means more people feel comfortable calling a doctor's office and saying, “hey, I want a doctor, I want to visit.” That's not necessarily a bad thing.
The reality is there's more demand in the United States and in the Western world than a lot of countries around the world, because people are healthier and they want to protect themselves from other sorts of things that are going to come in the long run.
Medical expenses are [largest] toward the end of life, they aren't really concentrated only in that last year. The average age of the US population has risen by a number of years over the last 30 or 40 years. We're no longer a country where the average age is in the 30s. We're a country where the average age is in the 40s.
As the population ages, the demand for health care goes up among that population. There are other things that have also hurt our increased good demand for health care. We have more ability to do testing and realize that people have certain diseases, and so that drives up demand for health care.
Federal Newswire: What would it take to bring in doctors from abroad?
Wolfson: There are six states that have passed legislation that allows a doctor who is licensed outside the United States to come to the United States and practice medicine without repeating residency.
The number of residency slots that the federal government funds [was] capped in the 1990s, and there's been some growth. The growth rate was staggering in the 1990s because there was a fear that we were going to have too many doctors in the United States, which is kind of crazy. They capped the funding. As a result, we've seen residency slots kind of lock in place.
…Too many of the conversations about how to deal with this have focused entirely on medical school. They've said, “let's open another two dozen medical schools and we'll train another 5000 doctors, and now we've addressed our shortage.” I say, and many other people who have thought about this say, unless you're going to increase the number of residency slots, then what you're going to have is a lot of people with an MD next to their name because they graduated med school, they don't get a residency, and now they're going to be in the worst of all possible spots.
They're going to have all the debt from medical school. They're going to have a great amount of training and they're gonna have nowhere to work.
Federal Newswire: What should the government do?
Wolfson: One of the things that we believe at the Cicero Institute is that if the government is going to do something, it should do something as well as it possibly can.
We think that if you can figure out how to make a government program run well, then it justifies the expense of that government program. Not because every government program is needed. But if the people of the state or the country have decided they want to do something, then let's have government do it as well as it possibly can.
One of the interesting things in medical school is the first two years are taken up with a lot of courses that most of those kids have already done. I've talked to some people who think maybe we should truncate the length of medical school in the United States for folks who already had science degrees, and allow them to skip or test out of the first two years of medical school and get right into clinical rotations where they're really learning to be a doctor.
We don't want to change standards. But the reality is, there's already malpractice that occurs when people who've gone through all the training. It's not like we have a foolproof system in the status quo.
Federal Newswire: In the short term, how do you think we can increase the number of doctors?
Wolfson: There are already a lot of doctors in the United States who are qualified. There are a number of folks who would be able to qualify if they weren't required to repeat residency. There are also US citizens who live in other parts of the world who might be interested in coming back, and some of them would seize opportunities to come back.
I also think there are thousands of doctors all over the world who are interested in coming to the United States. The number of international licensed doctors who are applying to try to get residencies in the United States [are] in the thousands every single year.
Lastly, there are also thousands of doctors around the world who would look at the income differential and the opportunity to make significantly more money. This isn't just making more money coming from a developing country to the United States. Most European countries pay their doctors significantly less [than our lowest paid doctors in the United States.
Federal Newswire: What is the Cicero Institute doing in telehealth and telemedicine?
Wolfson: One of my colleagues, Josh Archambault, has done a ton of work. He puts out an annual report ranking states on where they sit on their telehealth policies. We believe at Cicero that doctors who are licensed in one state should be able to get on the phone or a video chat with a patient in another state and provide them a consultation for a prescription.
I live in Virginia. If I called my doctor today from North Carolina and said, “hey, I've got this thing going on,” and it's something that he's treated before, my doctor legally shouldn't do anything for me. He would, because he knows I'm not going to report him to the Virginia Medical Association or to the North Carolina Medical Association. But the reality, legally speaking, is that he would be practicing in North Carolina without a North Carolina license. That's legally a problem.
Now, lawyers create all sorts of problems. I'll be the first to admit it, but this is one of those problems that lawyers and doctors have almost colluded to create. That doesn't make any sense in the 21st century. That might have made sense back when there were unique characteristics in different parts of the country, but the human body doesn't change. We think that you should be able to treat those patients across state lines.
