Free Market Fundamentalist

How Government Creates Shortages of Doctors

France, the Netherlands and the United States limited slots for medical students.

Westmaas Netherlands doctors office
Patients wait to see a general practitioner in Westmaas, the Netherlands (LHV)

Rural France is running out of doctors. Politico Europe reports that 7 out of 68 million French citizens don’t have a referring general practitioner. 30 percent live in a region where access to physicians is poor.

France is not alone. Small towns in the Netherlands and the United States are also medically underserved.

Partly the shortage is due to young doctors and nurses preferring to live and work in cities, much like young professionals in general.

Higher-than-usual burnout rates during the pandemic have exacerbated the shortage.

But government policy plays a role. All three countries for years kept the supply of doctors low while demand for health care, as a result of longevity and advances in medicine, went up.

France

France scrapped its cap on medical school slots in 2020. (Another long-overdue liberalization thanks to Emmanuel Macron.)

From 1971, the country had limited the number of medical students who could advance beyond their first year under the so-called numerus clausus. In 1972, the number was put at 8,600. It fell to a low of 3,500 in 1993 before climbing back up to 7,000 in 2007 and 8,000 in 2017.

Proponents argued the cap would control costs, but this never made sense. People don’t choose to get sick. Reducing the supply of health professionals doesn’t reduce demand for their services.

France’s medical association knew that. They supported a cap not in spite of the shortages it would cause, but because of it. It meant doctors could raise their fees.

It will take years to make up the shortfall. France has relatively few doctors per capita: 33 per 10,000 compared to 41 in the Netherlands, 44 in Germany and Spain, and 55 in Portugal.

Netherlands

Dutch universities still cap the number of first-year dentistry and medical students. Here it’s called the numerus fixus. This year there are 243 slots in dentistry and just over 3,000 in medicine.

There is no shortage of surgeons, but the Netherlands has a shortage of general practitioners. One in three are understaffed. It is not uncommon to move into a new town and being refused by the local GP. This most often happens in Drenthe and Zeeland, two lightly populated provinces, and the Achterhoek, a region on the border with Germany.

To fill in gaps in dentistry, practices recruit abroad. One in five dentists working in the Netherlands were educated elsewhere, often in an EU country like Portugal or Spain. There are still too few. The government regulates prices, since basic dental procedures aren’t covered by insurance. When it lifted price controls in 2012, dentists more than doubled their rates.

United States

The United States has the fewest doctors per capita among rich nations: 26 per 10,000.

It used to be the other way around: before Congress curtailed medical residency slots in 1980 — an American version of the numerus clausus — the United States had relatively more doctors than other democracies.

That became a problem when the government took over health care for seniors (Medicare) and the poor (Medicaid) in 1965. Medical residencies were funded through Medicare, generating additional costs to the federal government. Capping residencies was a way to keep costs down.

As in France, the cap only benefited doctors. Their salaries rose at twice the rate of inflation. Americans pay twice as much of their income on health care as they did in the 1980s, and twice as much as Europeans.

Education isn’t everything

There are more ways governments keep health care understaffed, as I’ve argued here before.

EU countries have got better at recognizing each others’ medical certificates and diplomates. In America, states don’t. If a doctor moves from Massachusetts or South Dakota — states without shortages — to Alaska, Arizona, Maine or Utah — the states with the highest shortages — they need to get a new license.

Nurses are seldom allowed to carry out even routine medical procedures without a physician looking over their shoulders. Some states relaxed those rules during the pandemic, and patients didn’t even notice. France is doing the same.

Few schools restrict the number of nurses they train. When they are oversubscribed, they just hire more teachers. And that is the reason nurses are underpaid. Care homes, clinics and hospitals for years didn’t feel a need to raise salaries or otherwise improve working conditions for nurses. For every one that quit, there would be a recent graduate to take their place.

Only in recent years have low pay and the high demands of the job contributed to a nursing shortage, again exacerbated by the pandemic. Dutch readers can check out my story from 2021 on this.

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