• Adam Smith’s Handshake with Hippocrates: Are National Health Systems ‘The Deciders’ of M.D. Career Choice?

      Miller, D. Douglas (2011)
      Abstract Background The U.S. and Canada have evolved their national health care systems triggered by policy actions and shaped by market forces. Neither country regulates M.D. graduates career choices, resulting in primary care versus specialty physician workforce imbalances. All U.S. and Canadian graduates must interface with national health system elements for clinical training. The impact of federal health care policies (as regionally implemented) and the general economy (with regional market variability) on medical school graduates’ free market career choices is unknown. Methods Health care insurance policy actions (i.e. federal laws) and economic events (i.e. recessions) between 1980-2010 were characterized and quantified for comparison to medical school graduates’ career choices reported annually in the U.S. graduation questionnaire (GQ) and the Canadian GQ. Part I evaluated the timing, degree and associated secondary effects of economic growth & recession cycles at the national, regional and personal financial levels. Part II chronicled major national health care policy events and market sector trends, including federal-regional implementation interactions and subsidies to the states, provinces & territories. Part III compared economic and health care policy evolutions to GQ and CGQ responses over the same time period. Results (Part II) There were >10 major U.S federal health care laws passed between 1980 and 2010, as compared to one in Canada in 1984. A transient 1990-95 decline in funding of Canada’s single-payer health insurance plan was rectified by public policy renewal in 2003. U.S. policy after 1995 fostered private sector co-insurance options, incrementally achieving a more balanced public-private insurance marketplace by 2005. State and provincial & territorial compliance with federal policy mandates varied based on regional wealth and health disparities, necessitating both federal subsidization and performance-based rewards/penalties. Numerous U.S. health policy stakeholders and care delivery agents increase system complexity and add costs that threaten sustainability. ACA implementation is a source of continuing U.S. uncertainty. Conclusions (Part II) More than 10-fold greater U.S. health care policy activity, compounded by greater regional variability and public-private delivery system complexity, has created vastly different clinical educational environments for U.S. and Canadian medical students. Recent U.S.-Canada health care universality policy convergence may influence future M.D. workforce profiles in both countries.