September 26, 1974
Page 32753
MEETING HEALTH MANPOWER NEEDS
Mr. MUSKIE. Mr. President, S. 3585, the Health Professions Educational Assistance Act of 1974, which was passed by the Senate this week, addresses among the most critical of our health problems: The lack of sufficient medical manpower, distributed adequately among all areas of the Nation, and equipped to serve all the health needs of our people. Medical manpower problems demand a firm response from the Federal Government, including financial support for health manpower training, and incentives for producing the health personnel we need most, located where the need is greatest.
Present physician manpower resources are beset with four acute problems: Geographical maldistribution, specialty maldistribution, a too-heavy reliance on foreign-trained physicians, and an uncoordinated system of licensing doctors and dentists to practice.
The problem of geographical maldistribution, for instance, is illustrated by the concentration of physicians in a few "doctor-rich" locations while rural areas and inner cities are underserved. In Maine the ratio of doctors to the civilian population is only three-fourths of the national average, and the ratio is even lower in some counties of my State. Geographical maldistribution is growing worse, with the physician-population ratio increasing almost four times as fast in "doctor-rich" areas as in "doctor-poor" areas.
The problem of "specialty maldistribution" has been marked by a disappearance of the family doctor – the general practitioner equipped to serve the normal health needs of the public. With more and more physicians choosing to practice specialized forms of medicine, the patient is often faced with the challenge of diagnosing himself before he can decide which doctor to see.
Specialty maldistribution is increasing: Nationwide, the number of physicians in general practice has declined from 50 percent in 1949 to 36 percent in 1960, and to 22 percent in 1970; in Maine, the number of doctors in general practice declined by percent from 1968 to 1972, from 282 to 251.
A third physician manpower problem is the increased reliance on foreign medical graduates, needed to make up for the inadequate capacity of domestic training facilities. Today, graduates of foreign medical schools make up one out of five physicians practicing in this country and one-third of all physicians in residence training programs, and receive about one-half of the new licenses granted annually to physicians in the United States. The vast majority of the foreign- trained physicians entering this country in 1972 came from developing countries, who themselves have acute medical manpower needs. And although many foreign-trained physicians have received a good medical. education, many others receive training inferior to that provided by domestic medical schools, with the result that citizens they serve may receive substandard care.
The fourth physician manpower problem is the variation in license requirements for physicians and dentists from State to State. Although almost all States now require a national examination. for licensure, the standards for success or failure on the same test differ. And some States do not recognize physicians licensed elsewhere, restricting the entry of doctors. The varying licensure requirements are particularly important in the case of foreign medical graduates, who practice in some locations without fully meeting licensing requirements, and sometimes with inadequate command of English.
Mr. President, adequate medical manpower resources will be essential to the goal of giving every American access to high quality health care. To achieve that goal, the Federal commitment to strengthening health manpower resources must be firm and clear.
This week, the Senate considered several legislative proposals designed to meet our health manpower needs. The basic legislative proposal before the Senate was the bill reported by the Labor and Public Welfare Committee as S. 3585. In its original form, that bill would not only have allocated substantial Federal funds for health manpower training, but would have also required the immediate implementation of a system of obligated service for all medical students, Federal standards for licensing and re-licensing physicians and dentists, and Federal determination of the distribution of medical manpower training in various specialties. The obligated service provisions of the bill would have required each medical school receiving Federal assistance to assure that it would require entering students to contract with the Federal Government to serve for at least 2 years after graduation in medically underserved areas as designated by the Secretary of HEW. The bill would also have required the Secretary of HEW to establish minimum national standards to licensure of physicians and dentists, including provisions for relicensure – by meeting requirements other than written examinations – at least once every 6 years. These minimum national standards would have taken effect in 2 years in States whose standards did not meet or exceed those proposed by the Federal Government.
Further, that bill would have established a system of national and regional councils to recommend limits on the number of training positions for physicians after graduation in each of the medical specialties, in order to insure that enough doctors would enter general family practice rather than entering specialties which already have sufficient manpower.
I had serious reservations, Mr. President, about establishing Federal control in this form over the health professions – particularly the requirement of Federal standards for licensure and relicensure of physicians and dentists, and the mandatory requirement that all students entering medical school be obligated to serve, after graduation, at the designation of the Federal Government. Although our medical manpower needs are serious, the case has not yet been made, in my judgment, for immediate implementation of those provisions.
When this measure came before the Senate earlier this week, two alternative substitute proposals for the original version of S. 3585 were proposed. One proposal, advanced by the Senator from Maryland, contained no provisions relating to licensure, relicensure, or specialty distribution, and instead of the mandatory obligated service provision would require medical schools to reserve at least 25 percent of their entering classes for students who made voluntary commitments to serve in areas with the most severe medical manpower needs. A second proposal, advanced by my distinguished colleague from Massachusetts (Mr. KENNEDY) would have retained the funding structure of S. 3585 as originally reported, but limited the effect of the bill to only 2 years, and deferred the implementation of the system of obligated service, national licensure, and specialty training limits until 1980. Under that substitute, the existing system of voluntary programs would have been given a renewed opportunity to solve health manpower problems before the more severe federally controlled solution to them would have been implemented. I supported the second alternative because in my judgment it best expressed a strong commitment to achieving significant improvements in health manpower. Before final Senate action, however, that alternative was disapproved, in favor of the substitute proposed by Senator BEALL.
Despite disagreements about the specific form of future Federal action to support improved health manpower, I believe the Senate's final action yesterday in passing S. 3585 as amended did demonstrate broad consensus on the importance of that goal. I hope that House action on a comparable measure can be swift, so our commitment can be written into law this year.