Sending a policy signal: state legislatures, medical schools, and primary care mandates

In the past few years, eleven states have directed medical schools in their states to produce more primary care practitioners or to change the training of physicians to make careers in primary care more attractive to medical students. This article outlines the progress and politics of the states' desire to hold medical schools accountable for producing more primary care practitioners. It analyzes the coerciveness and scope of the laws, including the provisions for implementation and accountability. Interviews with legislative staff, legislators, and university and medical school lobbyists provide information on the measures' political rationale and expectations. Most striking was the signaling nature of the provisions. The laws were not strident or especially onerous; they contained many loopholes and no real sanctions. They were important, however, in the message they conveyed. In state after state, legislatures sent a message to the medical schools that they were part of the solution to distributional problems of health care delivery and must be responsive to legislative desires for action. State legislators sent a policy signal, and most medical schools apparently understood its significance.