California's efforts to expand health care to all residents have drawn sharp warnings from the medical community that the increased demand for services will overrun a system already stretched dangerously thin.
The state is already grappling with a critical shortage of doctors, nurses and other health workers, and experts say any plans to expand coverage must also include programs to boost recruitment, training and retention.
"We graduate about 6,000 nurses a year in the schools in California," said Jim Lott, executive vice president of the Hospital Association of Southern California, which represents 190 medical centers. "We need to literally double that amount to begin to supply the needs we have currently.
"And we have shortages in other areas, too, like physical therapy, laboratory technicians, respiratory therapists, pharmacists and pharmacy technicians.
"It's creating a huge void, and in some cases, the problem is not being able to provide the care we are asked to provide."
California hospitals already have about 14,000 vacancies for registered nurses - about 35 openings at each hospital. That shortage is expected to grow to nearly 50,000 by 2010.
The Los Angeles area has the greatest nurse shortage - about 10,000 - which is expected to double over the next two decades, according to a recent report by the Center for California Health Workforce Studies at the University of California, San Francisco.
The problem is exacerbated, experts say, because people without medical insurance often suffer from chronic illnesses, such as hypertension and diabetes.
"These are people who have many medical needs," said Dr. Neil Parker, senior associate dean for student affairs and graduate medical education at the David Geffen School of Medicine at the University of California, Los Angeles.
"That will drive up demand, and therefore your work force is going to be impacted even more. It will worsen the nursing crisis, worsen the looming physician shortage and accentuate the pharmacist shortages."
Solutions sought
Sabrina Lockhart, a spokeswoman for Gov. Arnold Schwarzenegger, said the governor is aware of the shortages and has been trying to resolve it.
Among his solutions is a $90 million California Nurse Education Initiative unveiled in 2005 to help colleges expand nursing education.
"It really took a multi-prong approach in addressing nursing shortages by expanding capacity, by not only training more nurses, but helping to keep them in the field," Lockhart said.
"And it created incentives for nurses to be part of the education process to help bring on new nurses. It's really about recruitment and retention."
Since Schwarzenegger took office in 2003, the Office of Statewide Health Planning and Development has awarded more than $6 million for medical professional training in areas where shortages are most acute.
Dr. Anmol S. Mahal, president of the California Medical Association that represents 35,000 doctors, said the governor's plan for expanded health care does not adequately address staffing, but he is hopeful changes will be made.
"This is just a proposal," Mahal said. "And he's really open to suggestions. I think the conversation on what needs to be done is just beginning, and it's going to be an ongoing conversation."
In addition to Schwarzenegger's, health care proposals have been offered by Assembly Speaker Fabian Nuñez, D-Los Angeles, Senate President Pro Tem Don Perata, D-Oakland, Senate Health Committee chairwoman Sen. Sheila Kuehl, D-Los Angeles, and Republican lawmakers.
Plans differ
The governor's plan to offer health care to all Californians would impose new charges on doctors, hospitals and employers to expand coverage to an estimated 6.5 million uninsured residents.
The plans proposed by Nuñez and Perata focus on covering working Californians, rather than all residents, and would impose no fees on employers who don't provide employee coverage.
Kuehl's plan calls for a single-payer universal system into which all Californians would pay. They would receive coverage through a new government agency.
Charles Idelson, spokesman for the 75,000-member California Nurses Association, said the association supports Kuehl's plan because it would not exacerbate the nursing shortage.
"None of the other proposals are genuinely universal, and in some ways (they) may make the present mess even worse," Idelson said. "If you had a real universal health system that did encourage preventative care, then you would end up with fewer people in hospitals."
Dr. Ralph DiLibero, president of the 5,000-member Los Angeles County Medical Association, said any plan that is approved must boost medical staff.
DiLibero said schools lack the capacity and funding to train enough students, many students cannot afford the state's high costs of living, and a growing number of foreign-born medical professionals are returning home with U.S. educations.
"We, in California, have never trained enough physicians for our own needs," Mahal said. "We have been net importers of physicians from other states and from the rest of the world. In the past, that import was easy to sustain because we have the California lifestyle and the great weather to attract people.
"Unfortunately, it's not working as well now. California has some disadvantages. Physician reimbursements are lower, and physician incomes are lower in California than (in) other parts of the country. When combined with the high cost of real estate, it's a major deterrent to young physicians who come out of training with large medical school debts."
New schools needed
California is the most populous state in the nation, yet it ranks 39th in the nation in the number of medical students per capita at 16 medical students per 100,000 people.
There are 10 schools in California that are recognized by the state Medical Board as offering medical education. They admit an average of 1,340 first-year students annually and maintain an average annual enrollment of about 5,500 students.
But because of high teacher-student ratios, crowded facilities and other factors, there currently are far more people trying to get into medical and nursing schools than slots available.
"The waiting lists for students who want to go into nursing programs can be anywhere from six to 18 months long," Lott said.
UCLA has estimated that the growing pressures mean it needs to increase the number of physicians it trains by 30 percent in the years ahead.
"We need to increase the size of our schools for those that can increase," said UCLA's Parker. "And where we don't have the capacity in our current structures, we'll have to build more nursing schools, more medical schools and more pharmacy schools."
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