Roosevelt Institute | Cornell University

A Changing Labor Market for Healthcare Workers

By Philip SusserPublished April 25, 2014

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How will the Affordable Care Act impact who performs healthcare labor? \r\n\r\n
By Philip Susser, 04/25/2014


The Affordable Care Act's expansion of health care coverage was intended to provide underprivileged individuals — who under prior circumstances might not have found it financially viable to become insured — an affordable, easy way to gain access to a physician. Surely, this is a commendable and benevolent mission. Unfortunately, any such drastic policy change brings with it groups of conflicting stakeholders wishing to come out on top.  These groups range from doctors looking to sustain their profit margins to patients hoping to minimize out-of-pocket costs. One particularly striking recent conflict, though, is between physicians — and the Medical Associations that represent them - and nurse practitioners/physician's assistants.

While nurse practitioners and physician's assistants (PA) argue for increased autonomy in order to meet the newfound overwhelming demand for healthcare — specifically within impoverished areas — doctors feel strongly that supervision is needed for patient safety and well being. In Los Angeles, many nurses have objected to the reluctance of some doctors to open offices in the low-income areas that need them most. Nurses and PAs feel that they possess the abilities to provide comparable care to primary care physicians and that under the current health care scheme, their skills are being underutilized. In response to this outcry, medical associations contend that in giving nurse practitioners and physicians the ability to develop clinics, the United States could unintentionally develop a "two-tier" medical care system, where the wealthy are treated by physicians and the underprivileged see less-trained health care providers.

With both the aging of the baby boom population and the individual mandate, the shortage of primary care doctors will only increase in upcoming years. Not only does this legitimize the argument being made by nurse practitioners and physician's assistants, but calls for urgent policy action. Currently, about 20% of all Americans live in an area that experiences a shortage of primary care physicians. By 2020, the American Association of Medical Colleges predicts a shortage of 45,000 primary care physicians. How is the shortage coming from the supply side? For starters, many feel that doctors coming out of medical school — with considerable student debt — look towards the more lucrative specialties. Others have noted that the current hospital incentive structure is such that they find it most profitable to offer residencies in these lucrative specialties rather than primary care.

The question to ask, then, is whether there would be a significant difference in the quality of care provided by physician's assistants and nurses compared to doctors. Using data from high-income countries such as the U.S. and Japan, there was no significant difference in patient outcomes between patients treated by nurses and doctors. Institutions such as Harvard have developed models that allow patients with more routine symptoms to be treated by nurse practitioners and physicians assistants and patients with more complicated complaints by physicians. After all, about 20-70% of the tasks performed by doctors in the primary care setting can be performed by nurses.

Sixteen states have changed the scope of practice by nurses, allowing them to prescribe independently. In providing these healthcare providers the opportunity to utilize their skill set to the fullest extent, states can potentially save enormous amounts of money. In Massachusetts, increased responsibilities for these providers could lead to $4.2 to $8.4 billion in savings. With the United States model of primary care shifting to Accountable Care Organizations and community health centers, increased responsibilities for nurses can be a practical, resourceful way to confront the inevitable shortage of doctors.