Letters to the Editor
To the Editor:
January 2014 marks the beginning of health insurance coverage for millions through the Affordable Care Act (ACA) Marketplace and Medicaid expansion. But will the newly insured have access to quality health care? The United States faces physician shortages, especially in primary care.1 These shortages are most pronounced in rural areas, yet most of the nation’s residency training (and with it, most of the $13 billion in annual federal GME subsidies)2 occurs in urban settings. In a step toward addressing these issues, ACA Section 5508: Increasing Teaching Capacity authorized and funded teaching health centers with $240 million over five years to address primary care shortages. Teaching health centers should be permanently funded and expanded to provide interprofessional training to meet the needs of underserved communities.
Jolly et al1 report that residency slots in the United States increased 13.6% over the last 10 years in spite of the cap on federally funded positions. However, despite the overall increase in residency slots, 6.3% fewer medical school graduates chose primary care residencies. Because the decrease in those choosing primary care was leveling off from the prior year, the authors concluded that “the decline in interest in primary care careers may be ending.” Now is not the time for rosy primary care bromides. Had the number choosing primary care residencies grown at the same rate as the overall growth in residency slots in our teaching hospitals, the number of primary care residents would have also grown 13.6% from 8,624 in 2001 to 9,797 in 2010. The actual number in 2010 was 8,084—20% less than expected. Relaxing the residency cap, as some have suggested, would simply perpetuate producing too many subspecialist physicians in urban areas, and not enough primary care physicians anywhere.
Teaching health centers complement the outstanding training in urban teaching hospitals with interprofessional health professions training in outpatient, rural, primary care settings. Data suggest that this improves retention of medical resident graduates to practice in underserved and rural areas.3 Targeted residency expansion—to include interprofessional training with nursing, dental, and others—by expanding and permanently funding teaching health centers would build the community-based training infrastructure, prioritize rural training, and extend the training pipeline to areas of need. States expanding Medicaid under the ACA should consider aligning the almost $4 billion per year in Medicaid GME funding to assure an adequate health workforce through innovations like teaching health centers. An all-payer funding approach would lessen the burden on Medicare and Medicaid and more equitably distribute graduates to rural and urban underserved areas.
Daniel Derksen MD
Professor, director, Center for Rural Health, and
chair, Public Health Policy and Management Section,
University of Arizona Mel and Enid Zuckerman
College of Public Health, Tucson, Arizona;
1. Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474
2. Voorhees KI, Prado-Gutierrez A, Epperly T, Dirkson D. A proposal for reform of the structure and financing of primary care graduate medical education. Fam Med. 2013;45:164–170
3. Pacheco M, Weiss D, Vaillant K, Bachofer S, Garrett B, Dodson WH 3rd, et al. The impact on rural New Mexico of a family medicine residency. Acad Med. 2005;80:739–744