ACP American College of Physicians - Internal Medicine - Doctors for Adults

The big issues the candidates are not addressing: Access to primary care

Access to primary care

Between now and Election Day, I will be inviting your comments about the big health care issues that neither Senator McCain nor Senator Obama are addressing--or at least not emphasizing in the campaign.

Today's topic: the impending collapse of primary care medicine in the United States.

In January 2006, the American College of Physicians warned that primary care was heading for collapse, citing the decline in the numbers of young physicians choosing primary care specialties like general internal medicine, and evidence that general internists were leaving the field in greater numbers than subspecialists. The paper received a lot of favorable comment, but also a fair amount of comment that the word collapse overstates the problem.

Now, few argue the point that the United States is facing a huge shortage of primary care physicians for adults. A study published in Health Affairs estimates a shortage of 35,000 to 44,000 primary care doctors for adults by 2025. The Journal of the American Medical Association reports that only two percent of fourth year medical students plan to go into general IM. The message is getting out to the broader public as well: the November Reader's Digest writes that "soaring office costs demanding insurance companies, low Medicare payments, staggering debt, and politicians who refuse to make hard choices are driving primary care physicians out of business." ACP President-elect Joe Stubbs, a general internist in Albany, Georgia, was quoted by Reader's Digest as calling the primary care issue "an evolving crisis of unprecedented proportion."

Yesterday's Washington Post reported that the experiences in the two states have guided the health care reform proposals of Senators McCain and Obama: Senator Obama has looked to the Massachusetts experience, and Senator McCain has looked to Minnesota. As the Post noted in its article, "the large number of people who have gotten insurance [under the Massachusetts plan] and are suddenly looking for care has aggravated a shortage of family physicians and other primary-care doctors" in the Commonwealth.

So what have the candidates said about primary care? Not too much. As ACP's comparison of the candidate's positions shows, Senator Obama's plan mentions the importance of primary care and the need to reduce medical education debt, but that is about it. Senator McCain's plan does not propose any policies to address the primary care shortage, although the GOP's convention platform mentions its belief "in the importance of primary care specialties and supporting the physician's role in the evaluation and management of disease."

The problem for the next President is in the absence of policies to reverse the collapse of primary care, access and outcomes will be poorer and costs higher. Even if the new President and Congress could agree on a plan to dramatically reduce the number of uninsured, they may find that there aren't enough primary care doctors left to take care of them, just as Massachusetts has found. Giving someone an insurance card doesn't give them access if they can't find a primary care doctor to take care of them.

Today's questions for our readers: Do you agree that primary care is nearing collapse? If so, what should the next President do about it?

Labels: election, McCain, Obama, physician shortage

posted by BDoherty at 12:44 PM   4 Comments

Is health care a privilege, a right, or a responsibility?

One of the most provocative topics during this election year came in the form of a question posed by moderator Tom Brokaw during the October 8 presidential debate:

"Is health care in America a privilege, a right, or a responsibility?"
Senator Obama responded, yes, "It should be a right for every American." Senator McCain replied that "I think it's a responsibility, in this respect, in that we should have available and affordable health care to every American citizen, to every family member. . . But government mandates I -- I'm always a little nervous about."

The question of whether health care is a right or a responsibility--could it be both?--is explored in excellent commentary by Maggie Mahar. She writes in the The Health Care Blog that "The idea of health care as a 'right' is usually pitted against the idea of health care as a "privilege." Given that choice, I'll circle 'right' every time."

But she notes that defining health care as a right can come across as "shrill and demanding" and cites the views of a Dr. Shadowitz, an emergency physician and self-described "fellow traveler" of the "angry left" who writes in his "Moving Meat" blog that:

"When we use the language of 'rights,' we are generally discussing very fundamental liberties, which are conferred on us at birth, and which no government is permitted to take away: free speech; religion and conscience; property; assembly and petition; bodily self-determination; self-defense, and the like. Freedoms. Nowhere in that list is there anything which must be given to you by others."

Some conservatives are taking this view to create a legal bulwark against government-mandated coverage. George Will writes approvingly in The Washington Post of an Arizona resolution that, if approved by voters on November 4, would enshrine in the state's constitution the right of people to make their own health care choices without government interference. Resolution 101 reads:

"Because all people should have the right to make decisions about their health care, no law shall be passed that restricts a person's freedom of choice of private health care systems or private plans of any type. No law shall interfere with a person's or entity's right to pay directly for lawful medical services, nor shall any law impose a penalty or fine, of any type, for choosing to obtain or decline health care coverage or for participation in any particular health care system or plan." [Emphasis added]

Many doctors, fed up with government price controls that undervalue their services, may like the part about guaranteeing the individual's the right to pay for lawful services. Even so, physicians who believe, as ACP does, that the government must guarantee coverage should be concerned about Resolution 101. It turns the entire rights debate on its head, establishing rights that would limit the government's ability to require coverage instead of creating a right to coverage as health care rights advocates have long argued.

What do you think--is health care a right? A right to affordable coverage? Or a right to make health care decisions without government interference and mandates?

Labels: election, McCain, Obama

posted by BDoherty at 12:29 PM   11 Comments

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