HOUSTON - Universal healthcare opponents routinely point to long delays in getting medical appointments in other countries because too many patients take advantage of the fact that the government picks up the tab.

But the same problem exists if there are too few physicians. Unless Texas gets a grip on its healthcare work-force shortages, that's where it is headed. Texas has about 43,000 physicians to treat 23 million people, ranking 45th in the nation in physicians per 100,000 residents, according to the Texas Medical Association.

Texas will need 138,000 new nurses in the next seven to 10 years, according to a Texas State University study. But the Texas Higher Education Coordinating Board reported that the number of nursing students enrolled in Texas undergraduate and graduate programs in 2003-04 was 2,529. State medical officials say that more than 11,000 qualified applicants were turned away in 2005, largely because of faculty shortages.

The TMA and the Primary Care Coalition have embraced the aggressive recommendations for producing more physicians in Code Red, a 2006 statewide task-force report on Texas healthcare.

The report urged increasing the number of medical school graduates by 20 percent a year for the next 10 years. It also recommended that the number of residency positions be increased by 600 every two years for the next decade.

An equally aggressive November report from the Texas Center for Nursing Workforce said Texas must quadruple the number of nursing graduates by 2020 to meet the expected 86 percent increase in demand by that date.

According to a study from the University of Texas Health Science Center-Houston, Texas has 609 nurses for every 100,000 residents. The national average is 782.
Finding qualified nursing faculty is even more difficult than generating degree candidates. University instructors and community college faculty earn one-third less than they could earn in a clinical setting.

The Texas Hospital Association and the Texas Nurses Association are urging the Legislature to appropriate $39 million more for nursing education to boost enrollment and an additional $32 million to raise nurse faculty salaries by $10,000 a year. Earlier this month, Gov. Rick Perry proposed a pool of $360 million to reward colleges and universities for each graduate in crucial fields such as nursing and computer science.
Besides physicians and nurses, there are other shortages in healthcare workers.

Physical therapists, optometrists and pharmacists are in demand. As of 2004, 46 Texas counties had no dentists, and nearly 75 percent of the state's counties had a shortage of mental health professionals. The TMA says that specialties of particular concern are anesthesiology, pediatric subspecialties and cardiac surgery.

But primary-care physicians and registered nurses -- the front lines of medicine -- are buckling under the weight of inadequate numbers and burgeoning demand.

Limited access to primary care drives patients into emergency rooms, where care costs almost four times as much. About half of ER care could be done in a primary-care setting.
In Texas, 194 counties -- more than 75 percent -- lack an adequate supply of primary-care physicians. In 2004, 26 counties -- primarily along the border and in West and South Texas -- had no primary-care physicians.

Healthcare easily qualifies as the fastest-growing job sector in the 21st century. If current trends continue, 30 to 40 percent of all new jobs in the next 25 years will be in healthcare.
Healthcare now absorbs about 16 percent of the gross domestic product, and that is expected to grow to 25 percent by 2030 and employ 15 to 16 percent of U.S. workers. It is labor-intensive, with little threat of outsourcing.

According to a Business Week analysis last year, the 1.7 million increase in U.S. jobs since 2001 was due entirely to the healthcare sector. In the aggregate, all other job sectors were flat.

Healthcare workers accounted for more than 9 percent of the Texas work force, or 860,000 workers in 2004. The Texas Workforce Commission expects that to rise by nearly 170,000 by 2008 -- a 20 percent jump in four years.

Healthcare is the economy's hottest sector for myriad reasons. In addition to population growth, Americans are living longer, an obesity epidemic is spawning a number of chronic conditions, and medical advances are increasing the demand for additional services.

In Texas, a number of additional demographic factors are associated with public health problems: large pockets of poverty, a large percentage of ethnic populations that are more prone to debilitating conditions, a high uninsured rate, a high teen pregnancy rate, lower education levels and an unusually high obesity rate.

The state did virtually nothing to fight this battle for more than two decades. Until 2001, the TMA opposed expansion of medical school enrollment. For the previous 20 years, enrollment had been flat while the state added 8 million new residents.

This mirrored the national position, as the TMA's parent organization -- the American Medical Association -- opposed increasing the supply of U.S.-trained doctors despite an increase of 54 million in U.S. population. The nation relied primarily on foreign-trained physicians to practice in underserved areas.

Peter Hilsenrath, a health economics professor at the University of North Texas Health Science Center, contends that allopathic medical schools -- institutions that grant M.D. degrees -- were willingly complicit in the lack of enrollment expansion because they earn their revenue primarily from research grants and treating patients. Tuition does not cover the estimated $250,000 cost of training a medical student.

On the other hand, Hilsenrath said, osteopathic medical schools such as the UNT center -- which grant D.O. degrees -- depend heavily on tuition because they tend to generate little in research funding.

Texas is a net importer of physicians. Internationally trained doctors make up 21 percent of the work force, while 35 percent were trained elsewhere in the U.S.

The TMA says it abandoned its position on medical school expansion for three reasons:
A consistent increase in population, especially along the border.

A decrease in international medical graduates seeking certification through graduate medical education programs since the implementation of a clinical skills assessment exam was required beginning in 1998.

A decrease in the number of medical school graduates coming to Texas, blamed on the medical liability climate and increased penetration of managed care and its attendant headaches.

At least the state appears to have made significant progress on the malpractice front. The Legislature passed Proposition 12 in 2003, limiting pain-and-suffering damages to $250,000.

The results: The number of cases filed in 2004 was about half the number in 2001, malpractice insurance rates have declined about 14 percent, and medical license applications from out-of-state physicians rose 60 percent to about 4,000 in 2006, according to an analysis by the Texas Alliance for Patient Access.

An interim Texas Senate Health and Human Services report acknowledges the work-force shortages but lacks specific employment targets for legislative guidance. It urges increased residency slots, incentives to steer health professionals to underserved areas, programs to attract more healthcare faculty and reimbursement for telemedicine in rural areas.

All of that and more will be needed if Texas is to have enough doctors and nurses.