M.D. Monopoly: How Nurses Can Help Relieve Spiraling Health-Care Costs

By Bandlow, Doug | Policy Review, Fall 1995 | Go to article overview

M.D. Monopoly: How Nurses Can Help Relieve Spiraling Health-Care Costs


Bandlow, Doug, Policy Review


Medicare isn't the only part of America's health-care system where costs are spiraling out of control. Doctors have created a cartel by confining the delivery of treatment solely to M.D.s and by regulating the number and activities of M.D.s. This suppresses the supply of health-care professionals, raising costs and reducing choice. State governments could significantly lower both public and private health-care costs by reducing physicians' strangle-hold over medical care and moving towards a freer market. For its part, the federal government could, if it is willing to use its vast power under the commerce clause of the Constitution, preempt state rules that hamper the cost-effective delivery of medical services.

The Clinton administration recognized the problem of supply, but sought to remedy it by manipulating federal funding to force more doctors to become general practitioners. Similarly, the Council on Graduate Medical Education has urged educational changes to change the ratio of primary-care physicians to specialists from 30:70 to 50:50 by the year 2040.

The critical question, however, is not what percentage of doctors should provide primary care, but who should be allowed to provide primary care. Doctors are not the only professionals qualified to treat patients, yet most states needlessly restrict the activities of advanced-practice nurses (A.P.N.s) (who include nurse practitioners, nurse-midwives, clinical nurse specialists, and nurse anesthetists), registered nurses (R.N.s), licensed practical nurses (L.P.N.s), physicians assistants (P.A.s), nurse's aides, and similar professionals. Even today, these providers dramatically outnumber doctors--there are 2.2 million R.N.s, three times the number of M.D.s, and nearly I million L.P.N.s alone, while the number of A.P.N.s, at well over 100,000, is about half the number of physicians providing primary care. Ellen Sanders, a vice-president of the American Nurses Association, estimates that 300,000 R.n.s could become A.P.N.s with an additional year or two of training.

Although A.P.N.s, R.n.s, and L.P.N.s are capable of handling many simple and routine health care procedures, most states, at the behest of physicians, allow only M.d.s to perform "medical acts." According to Arthur Caplan, director of the Center for Biomedical Ethics at the University of Minnesota, "You have highly trained people doing things that could be done by others." Doctors perform what A.P.N.s could do, A.P.N.s do what registered nurses could handle, and registered nurses handle what nurse's aides could perform. "I can take care of a patient who has broken an arm," complains Maddy Wiley, a nurse practitioner in Washington state, "treat them from top to bottom, but I can't give them an adequate painkiller." Instead, patients can receive such treatment only through the government-created doctors' oligopoly, into which entry is tightly restricted. Observes Michael Tanner of the Cato Institute: "In most states, nurse practitioners cannot treat a patient without direct physician supervision. Chiropractors cannot order blood tests or CAT scans. Nurses, psychologists, pharmacists, and other practitioners cannot prescribe even the most basic medications."

The problem is exacerbated by the nature of the medical marketplace, where the expansion of services is expensive. Much of the necessary capital already exists--there are, for instance, a lot of unfilled hospital beds. The practice of medicine, however, has become increasingly labor intensive. The National Center for Policy Analysis figures that, because of the high cost of training medical personnel, "moving capital and labor from other sectors requires a price increase for medical services that is six times higher than that needed to expand other goods and services." As a result, the NCPA estimates, 57 cents of every additional dollar in U.S. medical expenditures is eaten away by higher prices rather than added services.

Physicians have shown unyielding resistance to alternative professionals. …

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