Thursday, May 27, 2010

Universal Coverage and Primary Care: The US needs both

In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website

Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:

Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.

“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”

Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.

Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors ( who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.

The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “

I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]

So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.

The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.

This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.

Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”

Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.

[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.

1 comment:

Josh Freeman said...

Comment from Dr. Starfield:

One of the points I was trying to make in the Health Affairs article was the need to unleash states to embark on single payer initiatives (as was the case in Canada) The article was written in anticipation of but before passage of the legislation in March, which PROSCRIBED single patient initiative until 2017---when exchanges will have captured the market. This amendment was added in almost secretively at the last minute. The effort now must be to repeal that amendment.

Total Pageviews