Penn bioethicist Art Caplan and I have had our differences, although sometimes we agree–as with most organ transplant issues.  Today, he has a piece out, what he calls “a reform reality check.” As do most bioethicists, he justifies rationing, and I think it is an inadequate defense.  (The problem of uninsured children can be fixed without establishing an invidious program of medical discrimination that pushes certain categories of patients out of the lifeboat.)

But that isn’t why I am writing this post. Caplan addresses a truly alarming issue I have not seen brought up before–a coming acute shortage of physicians. From his column:

Claim: If millions of Americans become newly insured, there won’t be enough doctors and nurses to handle them.

Reality check: This truly is a problem but it’s coming anyway. If current trends continue, the shortage of primary care physicians will reach 40,000 in a little more than 10 years, according to the American Academy of Family Physicians. Medical schools are only graduating about half the needed number of primary care doctors.

The overall shortage of doctors may grow to 124,400 by 2025, according to a study by the Association of American Medical Colleges. In a recent report, the researchers warn, “if the nation moves rapidly towards universal health coverage” which would be likely to increase demand for primary care and reduce immediate access to specialists, the shortages “may be even more severe.”

We need more primary care providers whether reform happens or not. We will need them sooner if reform does happen. What to do? Two simple ideas — forgive all medical school loans for any student willing to go into primary care and practice for a minimum of 20 years and extend more authority to nurses, pharmacists, physician-assistants and other health care professionals to help fill in the

But if Caplan has it right about this, and there is no reason to think he doesn’t, the last thing we need is a huge health care blue elephant partially paid for by further reducing already insufficient physician payments–as is currently proposed for doctors who treat Medicare patients. That is the exact wrong direction.

There is much to be done to expand access–such as establishing chains of local clinics for primary and urgent care, perhaps in shopping centers or other places where costs can be kept low, staffed by physicians assistants and certified nurse practioners (under the aegis of a physician), perhaps with government vouchers to help defray the costs for people of a certain income level.   (Caplan is right about expanding the authority of these medical professionals.) But if we don’t want the long waits for treatment or testing seen in Canada and the UK, if we don’t want the rationing of the UK and Germany (where doctors don’t tell patients of some care options), if we don’t want the right to care to be an empty promise because there are not enough doctors to provide it, as in Canada, we will not swallow Obamacare.  There is a better way.