With the revival of interest in health workforce policy come new twists. While some would say it is just the next cycle of the same old stuff, at least two aspects are distinctly different this time.

One of the most fascinating aspects of the revived interest in health workforce issues is the near universal acceptance of the assumptions and predictions of Richard Cooper. Considered to be the leading workforce policy expert, Cooper, a hematologist and former medical school dean who is now at the University of Pennsylvania, has developed and put forth the projection that the nation will experience severe shortages of physicians and other clinicians in the near future. These predictions have been accepted widely in the medical establishment, which is singularly remarkable given the long history of contention over disagreement about and inaccuracy in workforce policy activities.

Economy and Physician Supply

Cooper's projections are fundamentally different from the micro-focused efforts of the past, most of which were done by large government-sponsored committees that purported to use a complex needs-based approach in estimating the demand for medical services. Cooper and colleagues, working out of a small policy shop at the Medical College of Wisconsin, took a more macro approach and observed the strong correlation between the gross domestic product and the number of physicians. Based on this they postulated that as the economy grows so, too, does the need for medical care services and, therefore, the need for physicians.

Cooper's theory is based on the connection between the nation's wealth, its consumption of services and the number of health care providers needed to provide those services. Based on the assumption that the GDP will grow at a rate of 1.5% to 2.0% annually through 2020, Cooper predicts that the demand for physicians will exceed supply by 50,000 by 2010 and by 200,000 by 2020.¹ His work pertains specifically to physicians but also incorporates the rising number of PAs, NPs and nurse midwives. Were it not for their contribution to service delivery, the predicted shortage of physicians would be even larger.

Among Cooper's fundamental economic assumptions is the notion of continued growth in the American economy, which is not by any means assured. They also include the obvious considerations of an expanding and aging U.S. society, which in turn suggests the need to care for a higher number of persons with chronic diseases.

Uncertainty Abounds

Compared with previous workforce projections, Cooper's are remarkable in their simplicity and undeniable in their widespread acceptance. Yet predicting physician supply and demand is a very tricky area in which so-called experts have been wrong far more often than they have been right. There are several notable examples.

The Graduate Medical Education National Advisory Committee (GMENAC) in 1981 predicted that large physician surpluses would occur by 1990 and 2000. And as late as the mid-1990s, the Council on Graduate Medical Education (COGME) predicted that there would be an excess of physicians by 2000.² Neither prediction was even close to being correct. Other individuals and government groups have engaged in predictions of physician supply and demand only to be proven wrong as unanticipated events in the medical care sector occur.

So why, with such a history of uncertainty in this field, have we placed so much faith in Cooper's projections?

The answer is not clear. Most workforce experts and major medical organizations-particularly the American Association of American Medical Colleges (AAMC) and a good number of medical schools-have not only accepted Cooper's assertions but also have taken action to step up the supply of physicians. The AAMC indicates that 49% of U.S. medical schools have increased or probably will increase their enrollment.³ Cooper's projections have come to be accepted as the conventional wisdom.

The PA educational sector has begun discussions along the same lines, and preliminary findings from a survey conducted by the Physician Assistant Education Association indicate that a similar percentage of PA programs will increase or are considering an increase in enrollment, as well. The survey was discussed at October's PAEA Educational Forum in Quebec City.

End of the Federal Role

Another interesting and important difference between past workforce activities and what lies ahead is the absence of federal support. For decades, the federal government has been extensively involved in helping to shape workforce policy. The federal role in health workforce policy was prominent and included the funding of workforce study groups such as GMENAC and COGME, as well as programs that offered direct support to schools for training health professionals. That has changed, and the federal government is now perceived to be withdrawing from involvement in health workforce activities.

The present expansion of medical education is occurring entirely as a private-sector activity without the traditional federal subsidy. Were PA programs to expand their enrollment, it also likely would occur as a private-sector activity. What this means is uncertain. Federal support of health workforce training typically took into consideration perceived problematic areas that affected society and the health sector: insufficient numbers in primary care and in rural and underserved areas, and imbalances in racial or ethnic composition.

The questions for the future in health workforce policy become: Will private-sector expansion in the workforce address these issues? Can we attain the workforce we need without federal policy direction or subsidies? Only time will tell.

James F. Cawley is director of the PA/MPH program and professor and vice chair of the Department of Prevention and Community Health, School of Public Health and Health Services at The George Washington University in Washington. He also is professor of health care sciences at the university's School of Medicine and Health Science.

References

1. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21:140-154.

2. Summary of the Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC: Council on Graduate Medical Education; 1994. Available at: http://www.cogme.gov/rpt4.htm. Accessed October 31, 2006.

3. An analysis of medical school expansion plans. Association of American Medical Colleges' Analysis in Brief. 2006;6:2. Available at: http://www.aamc.org/data/aib/aibissues/aibvol6_no2.pdf. Accessed October 31, 2006.