The biggest problem with making health care accessible and affordable to everyone in this country is a shortage of physicians to provide it.
Extending coverage to the over 30 million Americans who are presently uninsured, as pending health-care legislation would mandate, is bound to create a big surge in demand for medical attention on the part of many who presently can't afford it. But there is already a national shortage of the very type of doctors who are most needed to supply it, and that shortage promises to get worse unless present trends are reversed.
The way the health-care delivery system is supposed to work, primary care doctors serve as the entry point for most people seeking care. They provide the routine physicals and wellness advice that everyone should get, diagnose and treat a great many ailments, and refer patients to specialists when warranted, while continuing to coordinate their care.
In nearly all other developed countries, the ranks of primary care doctors just about equal the number of specialists. But in the U.S., according to the American Academy of Family Physicians, only about 30 percent of practitioners are in primary care. Worse yet, the percentage of medical-school graduates going into primary care has dropped to 10 percent—that is at a time when a great many of those already in the field are approaching retirement age.
The academy's president, Idaho physician Ted Epperly, warns that, "If all of a sudden we give 30 million people health insurance, we will have a tremendous health-care crisis because we don't have the right type of doctors to care for them."
Such a crisis could not only make a mockery of the pending legislation's goal of extending health-care coverage, but also mean longer waiting times for appointments and less attention paid to those who already have it. That prospect is grim enough to give me pause in my oft-expressed advocacy of universal health care. But surely, I say to Epperly, there must be some way to resolve the problem and achieve a goal he shares.
His list of remedies starts with redressing what he considers to be inequities in the compensation of primary care doctors relative to specialists. "In the system as it's presently configured, Medicare and insurance companies pay exorbitantly large amounts to specialists to do things to people—say $5,000 to remove a gall bladder—whereas when I spend an hour with you to talk about your medical problems such as diabetes, hypertension, or depression I make $50."
Along with increased compensation for primary care doctors, Epperly says there's also got to be a reduction in the "hassles" they face. "The average family physician spends 17 hours a week on administrative matters, much of it on insurance company paperwork that could be handled electronically so that when we swipe your credit card we get paid immediately instead of waiting 90 days, which is the average now."
Beyond that, Epperly believes that medical schools need to be part of the solution through their student selection process, award of scholarships, and student-loan forgiveness programs for doctors who go into primary care, especially in under-served rural areas, "Right now the medical schools take no responsibility for the production of the work force, and it's imperative that they do so," he says.
Still, it takes seven years (four years of medical school and three years of residency) to mint a new M.D. So success in channeling more of them toward primary care can only be viewed as a part of a longer-term solution. In the shorter run, Epperly sees several ways in which the shortage can be alleviated.
One is to prevail on older primary care doctors not to retire anytime soon. "We have a very advanced age structure of family physicians in this country and could have as many as 25,000 retiring each year. If we could put a three-year freeze on retirements, that would give us 75,000 more," he says, adding that increased reimbursement rates and reduced hassle factors would help in doing so.
Another source of encouragement is rapid growth in the number of nurse practitioners and physician assistants entering these fields. Each of them requires only two years of training beyond college, and it's widely deemed that they can do about 85 percent of what a primary care doctor can. The number of NP's graduating each year has jumped from about 1,500 a decade ago to 6,000 this year, but with them as well there's a gravitation toward specializing that has to be overcome.
Some comfort can be gained from the fact that by no means all of the 30 million-plus uninsured people are going without primary care as matters stand. Some are well off young adults who can easily afford to pay for it, and many more with lower incomes are getting care from community health centers, such as Cherokee Health System in the Knoxville area, which would get a big boost in federal funding under the pending legislation. Moreover, the Knoxville Academy of Medicine purports to have a network of volunteer physicians offering primary and specialist care to anyone in Knox County who can't afford to pay for it.
In Massachusetts, whose mandated coverage for all represents a model after which the pending federal legislation is patterned, the president of that state's chapter of the AAFP, Dennis Dimitri, acknowledges that the 2006 mandate created "an unintended consequence: coverage but no access to doctors." But he adds that the newly covered are "slowly but surely finding a primary care doctor" and that the state is now taking meaningful steps to redress "the imbalance in the health care workforce."
For any health-care reform legislation to be worthy of the name, it needs to do so as well.