As we face 2008 and the challenges it will bring for the health system, it is worth thinking about the changing aspects of the nation's health workforce.

The health workforce comprises dozens of health professions and occupations, each vying for a piece of the turf of the rapidly expanding health industry. The U.S. Bureau of Labor Statistics estimates that more than 6.7 million persons fall into the category of "health practitioners and other technical occupations" (that includes PAs) within the U.S. health workforce.¹ Most experts believe that the number of people required in the future health workforce will only increase.

Government and Health Care

Like other components of the larger American health care system, the health workforce has become increasingly privatized, commercialized and fragmented. This status has come about as political leaders and the public have become more distrustful of federal government involvement in the health sector. This distrust has grown despite that there are demonstrated instances of successful programs funded and directed by the federal government that have tangibly benefited society.

The history of workforce policy since the 1950s reveals that an activist federal government has provided (and in some cases, still provides) substantial support for the education of health care professionals. Education for the health professions was a substantial growth industry in the decades of the 1960s and 1970s. In addition to the 40 new allopathic medical schools that opened after 1960, the federal government promoted and subsidized the establishment of the PA and NP professions, funded the institutionalization of graduate medical education in American teaching hospitals and championed the growth and development of nursing, public health, dental and allied health professions education.

Hospitals reaped millions of dollars to train physician residents, medical schools doubled their numbers and their output of graduates, and PA and NP programs thrived, all due in large part to federal subsidies. As one expert put it, "Health workforce policy has helped to attract, educate, and pay an enormous number of professionals to apply the diagnostic and therapeutic technologies of the late twentieth century. The only comparably successful labor policy in our history is the GI Bill of Rights."² This has resulted in a well-trained workforce that supplies the nation's health delivery system.

The Private Sector

But as is the case in other health care segments, a clear shift has occurred away from federal subsidy and control and toward the private sector, where market forces prevail. Changes in policy views about the health workforce?with the notable exception of nursing?reflect the questioning of assumptions on the value to society of public subsidies for health professions education.

The strongly private-sector entrepreneurial movement seen in the health care system is reflected in major segments of the PA profession. Take the example of PA education. There was a time when the federal government (public sector) played a major role in the promotion and development of PA educational programs, as well as medical and nursing educational programs.

The federal government, educational institutions, state agencies, insurers, health care regulators and professional organizations have separate and conflicting interests in key aspects of the workforce, including its training, financing, credentialing and scope of practice. This is why the health workforce is fragmented. What is most obvious is the lack of any single body that attempts to determine health workforce policy and better coordinate the functions of the various health professions. This stems in part from the fact that the states are responsible for licensing health care professionals.

Health workforce policy is very much involved with determining the supply and demand of the various health professions and is subject to bias and inaccuracy, particularly when it comes to predictions for the future. It is also ineffectual. One expert assessment states, "In the absence of a concerted and broad-based effort that spans everything from the size of professional school classes to the enhancement of reimbursement for provider disciplines in short supply, the production of a health care workforce of market-relevant size and distribution will be left to the fluctuating and often ineffective influences of supply and demand."³

No More Federal Subsidies

In terms of financing, the preparation of health care professionals will more closely resemble education in law, business and education. The point is that health professions education is now in a new era?pay as you go. The policy of government subsidies for health professions education is fading (albeit with certain exceptions, such as nursing), and privatization is the order of the day. Medical education is expanding to meet the anticipated demands of a growing and aging population. New osteopathic medical schools are starting, and allopathic schools are expanding enrollment. Yet unlike in the past, these schools are not receiving federal subsidies to support their efforts.

The expansion of PA education in the past 10 years has been a function of the private higher-education sector, not the result of a federal policy or federal subsidies promoting PA education. This likely will be the model for the near and distant future.

James F. Cawley is professor and interim director of the PA program at the School of Medicine and Health Sciences at The George Washington University in Washington.

References

1. Occupational Employment and Wages, May 2006. 29-0000 Healthcare Practitioner and Technical Occupations (Major Group). US Department of Labor, Bureau of Labor Statistics Web site. http://www.bls.gov/oes/current/oes290000.htm. Updated October 24, 2007. Accessed January 16, 2008.

2. Fox DM. The political history of health workforce policy. In: Osterweis M, McLaughlin CJ, Manasse HR Jr, Hopper CL, eds. The U.S. Health Workforce: Power, Politics, and Policy. Washington DC: Association of Academic Health Centers; 1996:31-46.

3. Sultz HA, Young KM. Health Care USA: Understanding Its Organization and Delivery. 5th ed. Sudbury, MA: Jones and Bartlett; 2005:234.