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PERSPECTIVESome Thoughts On The White-Follows-Green Law
During my residency years there was a sardonic comment often applied to colleagues departing for lucrative practices. "White follows green," the adage went, meaning that doctors went where the money was. The provocative thesis of Richard Cooper and his colleagues has raised this flippancy to the level of an economic principle, suggesting an inevitability to the growth in the physician supply and the associated costs of an ever enlarging complement of medical practitioners. The problem with Cooper and colleagues’ thesis that physician supply consistently correlates with GDP (gross domestic product) or personal income is that it suggests a wealth-driven inexorability that is, by implication, dismissive of choices that might be made by medical educators, policymakers, or the public. To wit, it belittles the historical and current role of public funding in growing the physician supply, citing the "termination of federal support for undergraduate medical education and a progressive decrease in support for graduate medical education." The history of governmental budgets over the past forty years indicates otherwise. Starting in 1963 the federal government in conjunction with state governments embarked on a vast program of financial stimulus for medical education that included construction monies, faculty development grants, and capitation payments. By 1980 the number of medical schools had risen by 50 percent and the number of graduates, by 100 percent—a striking feat of public policy. The federal government, indeed, curtailed its program of incentives for medical schools in the late 1970s, but state governments have continued to provide substantial support for medical education at the two-thirds of the nation’s medical schools that are public.1 Since the inception of Medicare in 1965 and, particularly, since the implementation of the hospital prospective payment system (PPS) in 1983, Medicare has provided enormous financial support to graduate medical education through payments to hospitals based on the number of residents they train. Those payments now exceed $7 billion a year, or more than $70,000 per resident per year.2 Not surprisingly, this form of capitation payment has been associated with a rapid growth in the number of residents in training, from some 60,000 in 1980 to almost 100,000 in the mid-1990s. In an effort to control this growth, the Balanced Budget Act (BBA) of 1997 capped the number of positions for which Medicare would reimburse and made modest reductions in the level of payment. High levels of public financing have provided an impetus for the growth of the physician workforce in the United States. This has not been an inevitable phenomenon but, rather, one based on political decisions and the appropriation of tax dollars in support of medical education. If Cooper or others are asking the public to continue or augment these subsidies to medical education, the question obviously arises as to what benefits are to be anticipated. Will quality be served? Are we likely to improve our fairly mediocre health outcomes as a nation if we subsidize the training of more physicians? Will equity be served? Is there any likelihood that having more physicians will help reduce problems with the uninsured or health disparities in the country? What about the world after September 11? Are there not competing interests in the health sphere that might have a better claim on our public funds, such as improving the public health infrastructure or reducing destabilizing global health problems? I have argued elsewhere that we should increase the number of U.S.-trained medical students because we now graduate 5,000 fewer doctors per year than we employ as first-year residents.3 We close this gap annually by hiring physicians educated elsewhere in the world and putting them to work in our hospitals. The vast majority remain in the United States for the balance of their careers. This chronic condition is unfair both to young Americans who do not get the opportunity to study medicine and to governments and schools around the world who effectively subsidize U.S. medicine. Expanding medical education opportunities (more schools or larger classes) in this country while holding residency positions constant would remedy this inequity without increasing the ultimate size of the U.S. physician workforce—a position that has public benefits worth considering. It may be inevitable that white, on its own, follows green. In the past half-century, however, we have spent many billions of public dollars training physicians and helping the slope of physician growth approximate the slope of GDP growth. This is not an inevitability. If the market for physician services is sufficiently robust that it generates new training programs, so be it. But any governmental body that is invited to finance more medical education should ask tough questions about the public benefit anticipated from such an investment. The citizenry does not have to fund white to follow green.
Fitzhugh Mullan, a physician and Health Affairs contributing editor, was the head of the Bureau of Health Professions, in the U.S. Department of Health and Human Services, and of the National Health Service Corps.
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