July 28, 2021

Depoliticizing Healthcare Licensure: Making Competence the New Standard for Licensing the Healthcare Workforce

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In the United States, political considerations play too large of a role in the licensing of physicians and other healthcare professionals, relative to medical competence. Such considerations are responsible for many of the current shortcomings of the healthcare system, such as high costs and impaired access to care. In “Depoliticizing Healthcare Licensure: Making Competence the New Standard for Licensing the Healthcare Workforce,” Murray Feldstein and Robert Graboyes argue that competence, certified by competing institutions, should be the primary standard for licensing the healthcare workforce.

PROBLEMS WITH POLITICIZED LICENSURE

Feldstein and Graboyes present two overarching problems. First, America’s system of medical school admissions and residencies imposes arbitrary barriers to entry into the workforce for willing, competent would-be providers—both those trained in the United States and those trained elsewhere. These barriers, the authors note, create chronic and worsening shortages in the medical workforce. Second, political machination, not training and competency, sets scope-of-practice limitations on nonphysician providers (e.g., nurse practitioners, pharmacists, and optometrists). This makes it harder for highly trained non-MD professionals to use their skills to help ease the physician shortages.

Both problems emanate from a politicized system of licensure in which legislators make decisions (frequently motivated by politics) that restrict entry into the medical workforce. The current politicized system of healthcare licensure was adopted a century ago, the result of years of the American Medical Association lobbying on behalf of MDs. Politics continues to play a perverse role: it maintains a status quo that may put the interests of politicians or professionals ahead of the interests of patients, and it prevents the healthcare workforce from adapting to the evolving needs and rapid technological advances of the 21st century.

HEALTHCARE CAN LEARN MUCH FROM AVIATION

The certification of airline pilots offers a less politicized model for the training, testing, and licensing of healthcare providers while ensuring market competition. As Feldstein and Graboyes note:

• Pilots, like physicians and other healthcare providers, are professionals in a highly technical field—and like physicians, their competence is a matter of health, safety, life, and death.

• In the nonpoliticized system of pilot licensure, there are no statutory or de facto limitations on the number of people who may enter the profession.

• Pilots must meet established, transparent, and objective standards of training, knowledge, and skill to be certified, after which politicians may not arbitrarily restrict pilots from exercising those skills in the aviation marketplace.

• Pilots may legally perform specific ranges of services for which they have been trained and certified. In contrast, a medical license legally permits MDs to conduct a full range of medical services, regardless of training or competence. (However, as a practical matter, nongovernmental institutions such as hospitals can limit a physician’s range of permissible services.)

• Pilots certified in one area (e.g., small, single-engine planes) can obtain training and certification to expand their scopes of practice by adding instrument flying or large, multi-engine planes to their legal range. In contrast, scope-of-practice laws can prohibit nurse practitioners from obtaining additional training and certification to expand their range of services.

• For these reasons, pilot training and certification are driven more by market conditions, whereas medical training and licensing are driven more by political and guild-like considerations.

KEY TAKEAWAY

The authors suggest that both problems of politicized barriers to entry and scope-of-practice limitations can be eased by lessening the monopoly privileges conferred on state licensing institutions. In place of such monopolies, they suggest a system of state-accredited, private, competitive, professional boards to determine their certified providers’ scopes of practice. If competence were the criterion by which various providers were permitted to practice, market forces could facilitate the evolution of alternative pathways to identify, train, and regulate the healthcare workforce. This would reduce the influence of politicians in deciding who gets to practice—and how they are able to practice—making healthcare less expensive, more accessible, and safer.