Free Trade (in Doctors)

If physicians really cared about our health, they'd drop their iron wall against immigrant doctors

With its thousands of acres of universities, conservatories, libraries, bookstores, teaching hospitals, med schools, and other enterprises dedicated to sharing knowledge, San Francisco is a place where problems are no sooner identified than solved.

Take the problem of swelling, fever, lesions, and pain, for instance. The Bay Area, just like the rest of the country, suffers from a dire shortage of primary care physicians. The result is millions of Americans paying through the nose for insurance, then waiting dangerously long for doctors. Millions more simply postpone medical care, thus courting graver health problems and possible financial catastrophe.

A UCSF professor last month published a medical journal article highlighting the disease behind this symptom: medical doctors' greed.

It wouldn't be fair to ask doctors themselves to cure such an affliction. But thanks to San Francisco's aforementioned intellectual ferment, no sooner did the UCSF article hit the streets than another author across town proffered a perfect cure: international free trade in doctors.

"Our trade policy on manufactured goods makes it incredibly easy to bring products here. We're very, very far from that with doctors," said Dean Baker, co-director of the Center for Economic and Policy Research in Washington, D.C., who was in San Francisco Feb. 21 promoting his book The Conservative Nanny State, which argues that government subsidies for the rich hurt the poor. (See

Making it easier for overseas doctors to become licensed to practice in the U.S. while still in their home country, and then easing immigration here, would make health care cheaper and more widely available for all of us. Though it might dock U.S. physicians' salaries.

"I understand a lot of [doctors] are going to be upset. They took out big loans to go to med school," Baker said. "But life's tough. Mothers raising kids on $18,000 a year with no access to medical care — that's real tough."

In a Feb. 20 article in the Annals of Internal Medicine, UCSF's Thomas Bodenheimer, the Urban Institute's Robert Berenson, and Washington lawyer Paul Rudolf argue the reason that even people with expensive insurance can't find a regular doctor is simple. Primary care physicians earn median pay of $156,000 per year, while cardiologists, neurosurgeons, and orthopedists can earn $600,000 annually. Given that medical students aren't immune to greed, the number of them choosing to become family practitioners dropped from 14 percent in 2000 to 8 percent in 2005.

If this trend continues, there will be no new general practitioners left by my 50th birthday.

What to do from a doctor's point of view? In the Annals column, Bodenheimer et al. recommend jiggering the insurance company and MediCare payment formulas so that primary care physicians earn more money, while "reviewing" high specialists' fees.

Bodenheimer et al. note that doctors will resist any change that endangers their payments: "It's unclear whether the medical profession — with different specialties having distinct monetary interests and different estimations of the professional value of their work — can agree on substantial change in payment policy on its own," they write.

Thankfully, an economic expert from outside the medical profession was at Modern Times Bookstore the day after Bodenheimer's essay hit the streets, explaining how free trade in doctors would solve this problem.

Doctors in India earn around $20,000 per year. If they want to move to the U.S., they must first obtain a scarce work visa, and once here they must comply with one of many different U.S. state-licensing standards, even if they've already had years of experience as a physician.

This process could be streamlined by creating a system to efficiently and rigorously license physicians overseas, while expanding the number of immigration quota spots for doctors. This would boost the quality, reduce the cost, and expand the accessibility of medical care in the same way that falling tariffs have made high-quality cameras, cars, and computers cheap in the U.S.

As might be expected, Bodenheimer rejected this idea out of hand when I ran it by him. His response seemed to confirm his essay's assertion that physicians are too greedy to agree to any solution that might reduce doctors' pay.

"I find this solution about as awful as anything I could imagine," Bodenheimer told me in an e-mail. "It steals physicians away from nations who need them much more than we do. We can afford to train our own physicians."

In practice, America trains so few physicians that doctors can earn several times the salary of their average patients.

And the idea that free trade in doctors would create a physician shortage in the developing world is as fallacious as the idea that free trade in televisions creates a TV shortage in Korea.

Already, doctors from the developing world treat legions of patients from the First World, a phenomenon that actually boosts those countries' access to good health care.

Cuba, Singapore, India, Thailand, Brunei, and a half-dozen other countries are international destinations for what is called "medical tourism," where patients travel to seek cheap high-quality care. In Havana, for example, entire new hospital wings are devoted to dollar-paying foreign patients. This means medicine is one of the few Cuban professions where university students can actually find jobs. Profits, meanwhile, fund medical care for Cubans.

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