By Christian Hardoy 

Much has changed in healthcare since the 1990s: HIV infection is no longer a presumptive death sentence, minimally invasive and robotic techniques have redefined a variety of surgeries, and telemedicine has greatly expanded access to care. Why then, in the face of such remarkable advancement and change, has the number of doctors the U.S. produces each year not changed enough to meet the evolving needs of our population? The answer is Congress.

To become fully licensed physicians, there is but one path forward for medical students: residency. With the vast majority of residency programs subsisting on federal funds, an estimated 82% in 2018, the federal budget has a direct and frighteningly limiting effect on the number of physicians the U.S. produces. This federal bottleneck largely results from the Balanced Budget Act of 1997, which capped the number of federally funded residency spots at 100,000. Since then, the only increase has been the 2021 plan to add a mere 1,000 residency spots (phased in over 5 years). In context, that is a 1% increase in 24 years. In the same time, the U.S. population grew by 22% and, according to the Association of American Medical Colleges (AAMC), the number of medical school matriculants has increased by 37.5% since 2002. Based on the numbers, the shortage isn't stemming from a lack of need or medical school students, but rather a shortage of federally funded residency spots.

For the average American patient, this represents yet another barrier to receiving much-needed healthcare services. The simple fact is: there is no healthcare without doctors. Fewer physicians per person means fewer patients can receive care, or less time per patient.

While the need for physicians of certain specialties or in specific regions may vary, the U.S. as a whole is in the midst of a physician shortage that is just beginning. A report by the AAMC predicted a terrifying shortage of between 37,800 and 124,000 doctors by 2034. With more than two of every five U.S. physicians turning 65 or older within the next decade, a growing aging Medicare population in need of ever-more specialized care, a young population increasingly in need of mental health services, and a general increase in the total population, we can't ignore the growing demand for physicians.

The COVID-19 pandemic in particular has highlighted the importance of doctors and other healthcare workers like never before, as well as the increasing burden placed upon them. Hospitals across the country have been overrun and understaffed in varying waves throughout the last few years. According to a Mayo Clinic publication, 62.8% of physicians demonstrated one or more manifestations of burnout in 2021 compared to 38.2% in 2020, and over the same time period physicians reported increased depression and decreased satisfaction with work-life balance. The specific challenges of the pandemic may be unique, but this test of our fortitude is just a taste of the true crisis yet to come.

This predicament also begs the question: Why has so little changed in over two decades? The answer is complex. The prevailing Congressional sentiment in 1997 was that a failure to limit the number of residency spots would produce an oversupply of physicians and too steep a bill for Medicare's budget. But the current healthcare reality is markedly different. In spite of this, continued budgetary concerns, lack of widespread Congressional support, and a dearth of public awareness of the issue have all played prominent roles in hindering progress. With less than 10% of the bills proposed being passed into law in the last Congressional session (2019-2021), and healthcare spending focused on COVID-19-related research, testing, and economic aid, it is no surprise that sweeping residency-funding changes have been difficult.

However, this lack of funding progress is not to say that no effort has been made. Behind the scenes, former Sen. Bill Nelson (D-Fla.), former Rep. Joseph Crowley (D-N.Y.), and several others repeatedly attempted to pass legislation that would increase the residency cap more substantially. Astonishingly, eight previous iterations of their bills were proposed and rejected between 2007 and 2019. The latest iteration, introduced in March 2021 and sponsored by Sen. Robert Menendez (D-N.J.), is known as the Resident Physician Shortage Reduction Act of 2021 and seeks to increase federally funded residency spots by 14,000 over 7 years. A growth of 14,000 spots is likely too little to be a panacea for the physician shortage, but the passage of this bill would represent a sizeable first step. The addition of even more residency positions or a removal of the residency cap entirely would ultimately have a greater impact, but legislative progress is often incremental.

The failure to pass meaningful legislation may paint a rather bleak picture on the surface, but the COVID-19 pandemic, the overturning of Roe v. Wade, and now a surge in respiratory syncytial virus (RSV) in kids have undoubtedly thrust healthcare into the public spotlight. I believe the public understands the enormous value of physicians, and with incremental progress on this issue -- between the addition of 1,000 residency spots and proposed legislation for more -- Congress may be primed to finally invoke meaningful change. In its absence, we risk failing to correct a mounting crisis of our own creation: a physician shortage epidemic.

Christian Hardoy is a second-year medical student at UC Irvine School of Medicine, with an interest in healthcare policy and active involvement with medical education research, student mentorship, anemia research, and geriatrics.