Jeffrey A. Singer
Last March, a report from the Association of American Medical Colleges (AAMC) projected a shortage of up to 86,000 physicians, including as many as 40,000 primary care physicians. The report noted that, as of 2021, as many as 17 percent of active physicians were over age 65, with an additional 25 percent of the physician workforce between age 55 and 64, concluding, “it is very likely that more than a third of currently active physicians will retire within the next decade.”
According to a study of 15 major metropolitan areas by Merritt Hawkins, the average wait for a first‐time appointment with a primary care physician (PCP) is now 26 days. The wait is 31.4 days for an Ob‐Gyn appointment, 26.6 days for a cardiology appointment, and 16.4 days for an orthopedics appointment.
Most state licensing boards require physicians to graduate from an accredited medical school and complete at least one year in an accredited residency program before they are licensed to practice medicine. State licensing boards grant the Accreditation Council on Graduate Medical Education (ACGME) a monopoly on accrediting residency programs. In 1981, the American Medical Association (AMA), AAMC, American Hospital Association, and a few other medical specialty societies created the ACGME.
I have argued for expanding the scope of practice of other health professionals, from nurse practitioners to pharmacists to doctorate‐level clinical psychologists, to the full extent of their training to expand patients’ access to health care services.
Now Jay Greene, an education policy analyst at the Heritage Foundation, has weighed in on the issue by bringing attention to the critical fact that, for decades, the allopathic and osteopathic medical professions have kept a tight lid on the production of new MDs and DOs through the government‐granted monopoly they wield on medical school accreditation. For decades, the Liaison Committee on Medical Education (LCME), created by the AMA and the AAMC, and the American Osteopathic Association Commission on Osteopathic College Accreditation (COCA) have restricted the number of medical schools they accredit.
Greene correctly points out that this artificially reduces the number of domestic medical school graduates and suggests that, over the years, it has led to a growing proportion of doctors entering residency programs who have graduated from foreign medical schools. However, after reading Greene’s “Backgrounder,” I can’t help but conclude that he is more concerned about the number of doctors who are immigrants and graduated from foreign medical schools than he is about increasing patients’ access to health care services.
Graduates of foreign medical schools accredited by the Educational Commission for Foreign Medical Graduates (ECFMG) may apply to ACGME‐accredited residency programs in the United States, providing they obtain a J‑1 immigration visa. These graduates comprise most international medical graduates (IMGs) who seek residency slots in this country. American nationals who attended ECFMG‐accredited medical schools overseas don’t need a visa. The ECFMG was created in partnership with the National Board of Medical Examiners (NBME). States granted the NBME a monopoly on administering the standardized US Medical Licensing Exam (USMLE). Can you see a pattern emerging?
Upon completing their residency, international medical graduates who obtain H1B visas or permanent legal resident status (green card) may enter practice providing medical care to Americans.
State licensing boards require that fully trained foreign doctors who are licensed, working, and experienced in other countries repeat the residency training they already received in the foreign country in an ACGME‐accredited program in the US, which increases the number of med school grads competing for the scarce number of residency slots.
The Residency Bottleneck
Greene contends that medical school graduates have a surplus of residency programs to choose from. Yet, every year, roughly 8 percent of MD and DO med school graduates are left without a residency position during Match Week in the National Residency Matching Program. These graduates are left in a state of limbo: they can’t get the required residency experience they need for a medical license, and they can’t work in medicine. At the same time, while they must wait another year for Match Week, they owe hundreds of thousands of dollars in student loans. Several states have created a position called “Assistant Physician,” which enables these graduates to work as apprentices to doctors and gain experience taking care of patients while earning some money and waiting for the next Match Week.
Greene proposes that lawmakers rescind the monopoly they have granted medical school accreditors. This would open the accreditation market, make it more competitive, and likely result in a greater number and diversity of medical schools. This, in turn, should produce a greater number of American doctors. Stimulating free markets and consumer choice is always a good idea, and medical education is no exception.
Greene argues that if there were more American medical school graduates, fewer residency slots would be available for foreigners because graduates of American medical schools would gobble them up. There’s a good chance he’s correct.
To ensure he’s correct, Greene proposes that the government require residency programs to offer positions based on nationality rather than merit. He wants residency programs to accept Americans first and immigrants only after they have run out of American applicants—sort of DEI in reverse.
Greene argues for increasing the number of domestic med schools but dismisses the notion that there aren’t enough residency positions to accept all the new graduates, contending there are plenty of slots available for all the American med school grads.
However, unless states rescind the monopoly they grant the ACGME on accrediting residency programs, the doctor production bottleneck will persist, no matter how many more students graduate from US med schools.
If lawmakers adopt Greene’s proposal, the only change will be the increase in the number of IMGs driving Ubers relative to the number of American grads practicing medicine. People will still have to wait an average of 26 days for a first‐time appointment with a PCP. However, it will be more likely that the PCP will be an American rather than an immigrant. Perhaps, over several years, as more medical schools open to produce more doctors, the number of residency programs will increase to accommodate them, and the total ratio of doctors to patients will improve. But that won’t happen quickly.
If Greene is interested in creating access to a free, growing, and dynamic market for health care services, he should also call on states to rescind the ACGME residency accreditation monopoly. This would make opening more residency slots in response to demand easier.
Greene should also support granting provisional licenses to fully trained, licensed, and experienced foreign doctors who migrate to the US, sparing them from repeating their residency (and needlessly competing with recent med school grads for residency positions) and adding to the pool of physicians who offer services to Americans. Tennessee became the first state to enact such a reform in 2023. This year, several more state legislatures have enacted provisional licensing for IMGs. These foreign doctors receive full medical licenses after two or three years of practicing under a licensed physician’s supervision.
Let Markets Work, Let Patients Choose
The best way to increase access to health care would be to not only adopt Greene’s proposal to rescind the medical school accreditor monopoly but to add to it by rescinding the ACGME residency accrediting monopoly, granting provisional licenses to experienced foreign doctors already practicing in other countries, and removing government‐imposed scope of practice limits on the various other health professions so they can practice to the full extent of their training.
We would welcome more American medical school graduates. We should welcome international medical school graduates able and eager to provide health care services. And we should also welcome non‐physician health professionals trained to competently provide health care services. As with other goods and services, more choices and competition benefit consumers—in this case, health care consumers.
Instead, Greene makes a nativist/protectionist argument (“These foreigners are taking our medical jobs!”) for increasing the proportion of doctors who are domestically born and trained. Yet he does not address the problem of not having enough doctors to meet the growing demand of an aging American population while an aging physician population retires more quickly than it gets replaced.
