The proposed broad expansion of health care insurance to cover the bulk of the nation's uninsured has doctors here and across the nation bracing for a deluge of new patients into an already strained system.
"If the current legislation opens up health care for 46 million, it would kind of be like a dam breaking and flooding the entire valley," said Dr. Mack Worthington, chairman of the family medicine department at the University of Tennessee College of Medicine in Chattanooga.
Health care reform proponents aim to expand health care coverage to provide almost universal coverage to Americans. But physicians say they are worried that if current policies remain, there won't be enough medical providers, either in practice or in the medical school pipeline, available to take care of those new patients.
With or without the passage of universal health coverage, experts predict the shortage in primary care, in particular, will worsen in the coming decades, especially as the baby boomer generation ages and requires more medical care.
The United States is projected to have a shortage of 35,000 to 44,000 family physicians and general internists by 2025, according to a University of Missouri School of Medicine study published last year.
By the numbers
* 35,000 to 44,000: Projected shortage of family physicians/general internists by 2025
* 250,000: Number of active physicians (of all specialties) over 55 and likely to retire by 2020
* 7 years: Minimum length of time needed to train a physician
Sources: Association of American Medical Colleges
"It would be great if everybody had coverage, but at the same time I'm worried it's going to overwhelm the system," said Dr. Ted Bowers, a 32-year-old family physician who opened his practice in LaFayette, Ga., in January. "We already know there's a shortage of primary care (physicians). It's a little concerning that it's going to flood the system and could potentially overwhelm us."
Finding providers to serve rural areas already is a major challenge, said Eric Garrard, chief operating officer for system operations at Hutcheson Medical Center in Fort Oglethorpe. It took more than two years of active recruiting for the hospital to identify a primary care physician to join an established family medicine practice in Trenton, Ga., he said.
"It's very difficult to recruit and retain in underserved areas," he said.
Doctors here are worried that a vast expansion of coverage will go into effect before the medical industry is prepared.
"We've got to slow down and think. We have politicians who really feel like they've got to deliver something," said Dr. Collin Cherry, internal medicine specialist at Beacon Health Alliance in Chattanooga.
Exacerbating the primary care shortage is the declining number of medical students choosing the field, where the pay is less than many other subspecialties.
The number of U.S. graduates choosing a career in family medicine has fallen 27 percent between 2002 and 2007, according to the Association of American Medical Colleges.
"Most of our residents have $150,000 to $200,000 in debt" coming out of medical school, said Dr. David Seaberg, dean of the University of Tennessee College of Medicine in Chattanooga.
"A primary care position pays $150,000 to $180,000 starting out. A radiologist coming right out makes twice that much. It will never be level, but these disparities need to be reduced somewhat to encourage" medical residents to choose primary care, he said.
But practicing primary care physicians and medical school staff share some of the responsibility for encouraging young students to consider the field, Dr. Bowers said.
"There are lot of disgruntled physicians out there who like to complain about all of the stuff we have to deal with," he said. "Things have changed a lot in the last 20 years, especially. You tell a doctor you're in medical school and his response is, 'I'm sorry.'"
Some advocate adding more federally funded graduate medical education residency positions to bolster the ranks of physicians and general surgeons. The Balanced Budget Act of 1997 froze the number of federally funded residency positions, putting the burden on training programs to pay for any new positions.
"We really need to address and put dollars into graduate medical education," said Dr. Ken Hayman, emergency physician at Parkridge Medical Center and president-elect of the Chattanooga and Hamilton County Medical Society, at a recent Chattanooga Times Free Press roundtable discussion on health care reform. "We don't have enough residency programs, and money has not been put into that system in a number of years."
But Dr. Cherry points out that an expansion of residency programs may not help in the area of primary care, as many primary care residency positions remain unfilled.
This year about 95 percent of all residencies nationwide were filled, but of those, only 56 percent of the primary care residencies were filled, he said. A large number of those individuals probably will specialize eventually in areas such as gastroenterology or cardiology, he said.
Other proposals have emerged in the health care reform debate to increase the supply of general physicians, including reimbursing primary care doctors for coordinating patients' care, rather than just paying per-visit or per-procedure; providing medical school debt relief for students going into primary care and those who agree to practice in underserved rural areas; and expanding the role of nurse practitioners or physician assistants in community health centers, according to the Robert Wood Johnson Foundation, a private organization focused on improving health care.
Changes in the physician work force must occur sooner rather than later, said Jim Brexler, president and CEO of Erlanger hospital, at the recent health care forum.
"If health care reform were passed tomorrow, those (medical school) graduates don't happen the next day. Those are four-, six- and eight-year cycles to be able to see a change in the work force and those investments have to be done early and often," he said.