Why is it so hard to get medical care? And what should we do about it?

You may have noticed, should you or a family member or a friend have had a health problem recently, that it is difficult to get care. It is difficult to find a doctor (or a nurse practitioner, or any health care provider) who is available to add you to their panel. If you are lucky enough to have one, especially one who practices primary care (a family physician or general internist or geriatrician for adults), it is still difficult to get an appointment. If you think you just have a simple question, it can be difficult to get through to them to ask it. Sometimes you can get a nurse, or a medical assistant, or perhaps the desk clerk who may be familiar with some things enough to answer, but often they cannot. Many practices now have “patient portals” (e.g., MyChart ®) where you can post a question for your doctor (often in the form of “I have these symptoms but I can’t get an appointment; do you think I need to be seen?”) that, hopefully, they will answer before you are in extremis.

When all these methods fail, and you are still sick, you can visit an Urgent Care Center, sometimes run by local health systems and sometimes by private chains. They can care for many problems and do some tests, but a lot of things will lead to them sending you to the local Emergency Department. That is, of course, what you were trying to avoid, if for no other reason than the long wait (often hours, even if you have a severe problem that, once they diagnose it, can truly be an emergency; I wrote in the past about a close family member who waited 7 hours to be found to have appendicitis). Not all ED waiting rooms look like “The Pitt”, but it is not uncommon, especially in those centers who have the facilities to care for really dire problems needing urgent intervention (heart attacks, strokes, acute abdominal issues needing surgery, etc.) 

A big part of the problem is that there is a shortage of primary care physicians. This is worse in the US than in other countries but is becoming a problem elsewhere as well, as discussed by Dr. Kenny Lin in “Primary Care Supply and Access Challenges Around the World” on his substack CommonSenseMD. There are also shortages of other physicians (thus the line out the door of the cardiologist’s office), exacerbated by distribution problems (specialists tend to group in major cities and wealthier suburbs). But much of the delay in getting into subspecialists would be mitigated by having more family doctors and other primary care physicians. This works in 4 ways:

1.      The primary care doctor can take care of lots of the problems that people otherwise seek out subspecialty care for. Because you have a heart, it doesn’t mean you need a cardiologist.
2. If the primary care doctor identifies a problem that they think does require a subspecialist (say, a cardiologist) they can refer you to one who is less backed up because primary care doctors have done an assessment and identified that there is a problem requiring a subspecialist. This also makes the subspecialist more effective, because the people they see have already been assessed by a physician and they have a clearer issue on which to focus their attention.
3. Once the subspecialist does their assessment, makes their treatment plan, and initiates it, much of the follow-up can be done by the primary care doctor, freeing the subspecialist from needing to see so many follow-ups and having more appointments for new patient assessments.
4.  Many people (especially older people) have more than one health problem. Not only is going to a separate subspecialist for each potentially inefficient and possibly unnecessary, but can result in “communications problems” between them. This can be dangerous for the patient, in part because treatments for one condition sometimes worsen another. Having a primary care doctor who cares for the whole person, not just one organ system or disease, and is in possession of the assessments and plans from all the subspecialists, means the patient receives care that is coordinated and managed appropriately.

This model is understood and often utilized by subspecialty physicians who understand that their time and effort is best spent in the narrow area in which they are expert. The problem is that it requires a sufficient number of primary care doctors (about 40-50% of physicians), and, in the US, we don’t have them, and are not even moving in the right direction. As I have discussed before, a big reason that students do not choose to become primary care doctors is money…that their incomes are far less than subspecialists, and this needs to be addressed (see, for example, Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people, Sept 28, 2023).

Another part of the reason people do not access care is cost; the American Academy of Family Physicians (AAFP) newsletter Family Medicine Today reports on a survey by West Health-Gallup that 1 In 3 Americans Are Making Basic Living Sacrifices, Borrowing Money To Afford Health Care. Of course ‘…the “need to make these trade-offs was far more common among the uninsured, Gallup found, with 62% saying they made at least one sacrifice to afford their care. However, 29% of those with insurance also said they were forced to make a trade-off to cover their health care costs.” So…a big problem.

The cost issue may seem to be one that is more clearly related to my contention, in a recent blog (Feb 26, 2026), that The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., but in fact so is the shortage of primary care physicians and the difficulty getting appointments. On Feb 18, Health Care Un-covered addressed “The Economic Exploitation of Independent Physicians by Insurers”. It is also a result of practices being owned by profit-making private equity companies (or sometimes by insurance companies, such as UnitedHealth owning Optum) that determine the practice parameters and character, including the speed-up (seeing more patients more quickly) and other business approaches that are good for making money but not for people’s health. In addition, this includes the practice of replacing primary care physicians with less-trained non-physicians, such as nurse practitioners and physician’s assistants. I don’t mean to disparage these professionals, and indeed they can be very good and effective in the roles they are put in – seeing acute minor illnesses or checking on the status of chronic illness such as diabetes and hypertension. But being the coordinator, the “quarterback” – of care for the whole person that the primary care physician can fill, as I described above, requires more, not less, training. It makes care better; not the “most profit” or the “most efficient” but the “most likely to maintain and improve the patient’s health”. Even when for-profit companies don’t own the practices, “A wave of coordinated lawsuits is transforming the No Surprises Act’s arbitration system into a battlefield where insurers seek to intimidate physicians, rewrite the law and consolidate control” (How Insurers Are Using the Courts to Rewrite the No Surprises Act, Health Care Un-covered, Mar 11).

The health of the US population has long been worse, using generally accepted health parameters and measures, than in comparable countries. The situation is not improving, as insurers decrease access by increasing premiums and co-pays and deductibles, forcing a significant percentage of Americans to cut back on other necessities, as well as often denying coverage for important care. These practices control not only patients but physicians, along with the control exerted by hospital systems are for-profit ownership of physician practices. It also contributes to a downgraded role and lower pay for primary care physicians, who are key to maintaining health in the US and other countries. It is not a good situation, and it is getting worse, if Americans’ health is the measure.

It is past time for us to ensure that this is the measure, and not maximizing the profit of corporations!

Global Health at Home: Caring for Migrant Families on their U.S. Arrival

The American Academy of Family Physicians (AAFP) sponsors an annual Global Health Summit. This year’s conference, in Albuquerque, NM, was the largest so far. The conference started primarily as a venue for family physicians who volunteer their time abroad, providing health care and teaching in generally less developed countries. These were for both long (a year or more) or short trips, often sponsored by religious organizations. They also can include work done through government (eg, Peace Corps) or non-governmental but non-religious organizations (eg, Partners in Health, Doctors without Borders, Doctors for Global Health), but the religious root of much of this work is still apparent in the use of the term “mission trip” for most short-term such activities, especially involving medical students or residents. Overall, most such organizations, including those largely or partially sponsored by churches or religiously-affiliated organizations, no longer make religious proselytizing or efforts to “convert the natives” a significant part of these trips, and focus instead on health care and health system development (although there are certainly exceptions). Many of the leaders in this field are also involved in development of health systems in countries across the globe and in international health organizations and efforts including WONCA (the World Organization of Family Doctors), the World Health Organization (WHO) and its sub-groups such as the Pan-American Health Organization (PAHO), and The Network-Towards Unity for Health.

While such international work remains the mainstay of global health activity, there is also increasing interest in addressing needs in the US. To some degree, this reflects a long-standing discussion regarding the degree to which many doctors and students are more interested in going abroad on such trips than providing care to the needy at home. Of course, this need not be a contradiction, and many of the most active physicians in global health also spend the bulk of their time in the US working with underserved communities. But there are also those, including many students, who are attracted to such trips for other reasons. These include “medical tourism” – using the trip as an excuse for an exotic vacation, particularly if the place they are going is near beaches or mountains. They also include what might be called “medical opportunism”, where students go because they will get to do things to people on these trips that would be forbidden for them to do in the US, especially procedures. On the positive side, they can, provided the physicians or students are open to it and do not just talk to each other and can go beyond the “we are here to help you” mentality, allow learning and increase intercultural understanding, as well as increase knowledge of conditions that are more prevalent in the developing world. In addition, some of these conditions, as a result of the climate crisis and other factors, are moving north into our own country, so we see Chikungunya and dengue and other formerly tropical diseases. The key distinction is in how these trips are approached; they should be of benefit to you, but are not, ultimately, about you, but about collaboration with people, and health care providers, in other countries.

One increasing area of interest that tends to bridge this US/international divide involves the care of migrants coming to the US, an issue that has becoming increasingly front and center over the last few years. While the care is done in the US, the people are coming from other countries; in the case of our southern border primarily Central America and Mexico, but people come from all over the world. Several presentations at the Global Health Summit addressed different aspects of “Border Health”, each of which is important and each of which creates the need for linkages with other aspects of the health system. One is the care of people who permanently live along the US/Mexico border. The border, of course, is artificial, and many families live on both sides including Native Americans, such as the Tohono O’odham of Arizona, whose reservation crosses the border. This is a special case of care for the poor and underserved. Another is the care of people who are migrant workers, who may “live” in the border area for much of the year, but move to other regions of the US to follow the harvest. This creates the need for linkages with migrant health providers across the country. A third is the care of just-arrived migrant families who present at our southern border and may spend just a few days in our border communities before moving on to other parts of the US where they have sponsors. This creates the need for communication with appropriate health facilities in those areas, both for general health care and “warm hand offs” for individuals with particular needs. Such needs include those with ongoing chronic diseases often made worse by the journey, acute but severe issues such as injuries (including traumatic amputation by trains) and acute renal failure from dehydration crossing the desert, pregnancies (especially those that are high risk), and newborn but small or premature infants, etc.

“Global Health at Home: Caring for Migrant Families on their U.S. Arrival” was the title of a presentation by three Tucsonans who volunteer at the Casa Alitas migrant shelter, Anna Landau, MD MPH, Patricia J. Kelly, PhD MPH FNP, and myself. Originally accepted as a seminar, it was “upgraded” to a plenary presentation when the originally scheduled Ostegaard Speaker, Michael Kidd of Australia, was unable to attend due to family issues. While it was an honor to be selected, it was also gratifying to note the level of interest among the participants, from those doing similar work in cities on the border such as San Diego, El Paso, and Yuma, AZ, to those across the US who see these people as patients in their home communities, from big US cities to small towns in SW Georgia.

I have attached the slides in 'Links to Documents', found on the right side of the blog screen. It is important to recognize that medical care, which given the fact that guests are usually present for only 1-3 days, follows a public health model of dealing with acute needs and screening for infectious disease, is only a small part of the Casa Alitas operation. Hundreds of volunteers – and all are volunteers -- work on food preparation and service, contacting sponsors and arranging transportation, collecting and sorting and distributing clothing, doing laundry, driving guests to the bus station, and the multiple other needs that migrants have. I would also like to quote some parts of an email sent out by the Reverend Delle McCormick, a long-time leader in working with migrants in Tucson, after the recent move of Casa Alitas, which she has given general permission to share widely:

Every day is a triumph of small steps toward smoothly operating, warmly encouraging, just and loving spaces for our guests and volunteers. We have fallen for this new place and time. With each move we get more nimble, creative, and courageous in what we do together. Love shines here….Despite new draconian immigration policies at the border, we still have received 2484 men, women, and children at our new Casa Alitas Welcome Center shelter, making a total of 17,418 since October of 2018 when we stepped up our efforts to provide shelter for families seeking asylum.

Our volunteers still provide extra touches to encourage the human dignity and rights of every person who passes through our door. We hear and hold the most harrowing of stories: from 80+ year-old Sra. T. who stayed with us for a month because we couldn’t locate her sponsor, to the young man who had his toes burned off because he couldn’t pay for his release from kidnappers, to the woman who was shot in the head by her husband, to the daughter whose 68 year-old mother, who is blind, was detained, to the teenager kidnapped and prostituted and beaten by the local gang,  to the many, many others, each of whom has harrowing stories that drove them to leave everything behind to seek asylum.

If anyone is interested in learning more about the work in Tucson at Casa Alitas, in coming to volunteer, or in donating, more information is available at the website https://ccs-soaz.org. Donations can be made directly to CCS at  Support Migrant Aid - Tucson and through its GoFundMe page https://www.gofundme.com/casa-alitas-for-migrant-families.

Some medical care may not help. Alternatives may not either.

‘Why Doctors Still Offer Treatments That May Not Help’, by Austin Frakt in the New York Times, August 27, 2019, is a well-done article that, despite its title, is fairly optimistic. He reports that while about 50% of current medical treatments no not have good evidence supporting them, only 3% have evidence showing them to be harmful, and another 6% unlikely to be helpful. This means about 41% (or only 41%, if you prefer) have good evidence that they are helpful.

Frakt cites some of the research on health interventions that do not work, or may even harm, quoting leading researchers Vinay Prasad and Adam Cifu (although he does not mention John Ionannidis, arguably the father of the field). He discusses the important “Choosing Wisely” campaign, initiated by the American Board of Internal Medicine Foundation, that asks each medical specialty society to identify at least 5 things often done in their specialty which usually should not be done. There is not, however, always consensus. For example, among its 20 recommendations (a high number that continues to grow, perhaps because of its discipline’s broad scope), the American Academy of Family Physicians (AAFP) recommends against imaging (including MRI and CT) for uncomplicated back pain, as does the American College of Physicians (Internal Medicine) (see ‘Medicine should not be primarily a business: choosing appropriate care for all, not excess testing for some, August 19, 2018).  Yet, neither the American Academy of Orthopaedic Surgeons, or the various groups of radiologists who perform these procedures, make this recommendation. Of course, both stand to benefit financially from doing these procedures.

It is concerning to think that, at least in some cases, financial benefit may influence the selection of some medical societies’ “Choosing Wisely” recommendations. Sadly, it is not a surprise, and financial benefit is, I believe, the reason for the use of many unproven treatments. Another important reason is an understandable reluctance for providers to abandon therapies that they have used for many years and believe to be successful. After all, if 50% of treatments do not have good evidence that they help or harm, many probably often do help, even if most of the evidence is anecdotal. Much more malicious, however, is the intensive marketing of new drugs and therapies to physicians by drug and device makers with a strong financial profit motive.

Frakt provides a litany of therapies-since-found-not-to-work-or-even-do-harm, including hormone replacement for post-menopausal women. The only drug he specifically names is Vioxx®, the “miracle” anti-inflammatory pulled from the market when it was found to cause heart disease (at least publicly found; the manufacturer actually knew it before it was released!). He also mentions “tight blood sugar control in critically ill patients” (and actually, probably most patients). This certainly relates to drug. The plethora of new, expensive, and marginally advantageous diabetes drugs is a testimony to their profitability. Ironically, it is often the same physicians who are unwilling to give up on treatments that are unproven or even proven to be of no benefit or of harm who are the first to begin using new (and, redundantly) more expensive drugs heavily promoted by the manufacturers.

Of course, it is not just diabetes drugs that are expensive. Compared to some of the newer drugs for rare diseases they seem like a bargain. In “The $6 million drug claim”, Times writers Katie Thomas and Reed Abelson discuss a woman who has $1 million in drugs to treat her condition in her refrigerator! While in her case they were paid for by her husband’s union, the cost can still be backbreaking: “At one point in 2018, for every hour that one of the union’s 16,000 members worked, 35 cents of his or her pay went to Alexion to cover the Pattersons’ prescriptions.” And what about those who have poor insurance, or no insurance? Or a union that goes bankrupt paying for them? Alexion, of course, does well, though.

A new law allows “gravely ill” patients the “right to try” drugs that the FDA has not approved. It sounds good; as a friend told me “I figure if I’m going out and they want to try something that might kill me I haven’t got much to lose. At best I’m cured. At worse, I go out but knowledge is gained.” Except for maybe dying sooner or more painfully, or possibly going bankrupt. It is not uncommon for doctors to suggest something new, unproven, or even a treatment that has already failed, one more time. Not everyone in this country has good insurance, and if your insurance company appropriately refuses to pay because there is no evidence of efficacy (yes, they are sometimes right!), you are on the hook for the bill. You may be dying, but your family may need the money you were saving for retirement. Thus, there may be a great deal to lose.

A certain percentage of people will take all this to mean that mainstream medicine is not to be trusted. This is definitely an overreaction, although a healthy skepticism is warranted, especially when the treatment is incredibly expensive and it is obvious that somebody (or some corporation) is making a killing on it. Some people will decide to pursue only what used to be called “alternative” medicine. These practices, often with hundreds or thousands of years of experience, are often called “complementary” and are now frequently offered along with mainstream medical therapies in “integrative” practices. But the same cautions must apply; because something is different, or traditional, does not make it necessarily either effective or safe.

For example, while people sometimes believe it is safer to choose only “natural” medicine, because a therapy grows in nature does not mean it is necessarily safe. Earlier in my career, medicine virtually abandoned the use of digitalis, made from the natural plant foxglove, to treat heart disease, after it had been used for decades. The key point is that if a substance works biologically and has “good” (i.e., desired) effects it can also have “bad” (i.e., undesired, or “side”, effects). This is true if it is straight from the plant, modified and standardized, or completely created in the laboratory.

Another real danger is what Frakt calls “wishful thinking”. Being optimistic and hoping that things will turn out well is good, and often useful when confronting serious illness. But when this transitions into the realm of “magical thinking”, being convinced that something good will happen to you because you want it to (or vice versa, that something bad will not happen because you don’t want it to), or believing a treatment will work because it is “natural”, or because your doctor recommended it in the absence of evidence, it is a real risk. “Magical thinking” is normal in three year olds, but dangerous in adults.

So what to do? Be open to new treatments, but do not reject the old, whether “traditional” or medical. Ask for evidence for treatment, such as when just changing a drug from an inexpensive standard (say, metformin for diabetes) to a new, costly one. Learn to understand probability, and ask for numbers. Do not reject anything out of hand, but do not believe that something will work just because you want it to.

Stay skeptical but not intransigent. Look for the evidence. And look also, when something is expensive, for the profit motive. Cui bono? It may not always be you.