Racism and lack of social services: The status of women's health care in the US

A recent publication from the Commonwealth Fund is the 2024 State Scorecard on Women’s Health and Reproductive Care in which they rank all the states (plus DC) for how well that care is provided and the health status of women that results. The map below gives an overall sense (darker is worse), and the entire ranked list can be found in an interactive table in the document. 

The first thing that we see is that there are no real surprises. Massachusetts is at the top and Mississippi is at the bottom. The other top and bottom states are the usual suspects for almost anything that is beneficial to people, with the Northeast doing best and the old Confederacy doing the worst. There are always some minor shifts within those groups, and in this ranking we see that Louisiana* and South Carolina are only “worse than average” not in the “bottom performing states”, while disappointing to me, Arizona and New Mexico are in the lowest group. The reasons are a little different in different states; the Arizona legislature is (narrowly; we hope to flip it this year) controlled by Republicans who are as mean and nasty as those in the deep south. New Mexico is controlled by Democrats, but it is very poor. Poor is a big component of health status, and its fingerprints are all over this data on women’s health.  ‘Despite a small rebound in women’s life expectancy in 2022, it remains at its lowest since 2006,’ says the report.

Abortion care – access to it and the quality of it – has dominated the national political discussion. I don’t want to minimize it; it is incredibly important that women can have abortions, it is a privacy issue, and it will hopefully have major negative repercussions for the party whose agenda is to limit it. That the greatest restrictions on abortion are in the same states that have the worst women’s health status is neither a coincidence nor a surprise; the people who control these states and are anti-abortion are also racists and are unwilling to provide funds to improve the health standards of people who are women, minority, or poor – and especially all three. But it goes far beyond abortion:

For health outcomes, we measured all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence.

Abortion is not the major component of poor reproductive health status. Maternal mortality rates are shockingly high in the southeast, and worst in the Mississippi Delta. The US overall does not do very well in this area, especially as it is the richest country in the world. Data from the CIA (!) shows that in 2020, the US maternal mortality rate overall was 21/100,000, tied with Lebanon, Grenada, and Malaysia and just slightly worse than the West Bank or (pre-war) Gaza Strip. This was (and remains) much higher than Canada (11), UK (10), and most of Europe, including eastern Europe at 5 or less! (Note, showing the same dramatic racist differences as in the US, Israel is at 3). Of course, this overall rate in the US is driven by the states with the highest rates, with the worst states having a range of 34.1-51.7! While this is largely the result of excessively high rates in minority women, it is worth noting that the maternal mortality rate for white women in the US is over 19!

 

This is a good time to discuss the segmentation of results for maternal mortality (and all-cause mortality, and really most things) by race or ethnicity. In the bizarre, perverted, and of course racist excuse provided by many (racists) for why the US’ maternal mortality is so high compared to civilized countries, it is often said “it’s the minorities that drive the rate up”. In addition to ignoring the excessively high rate for US whites (19) it is scarcely an excuse; indeed, it is an indictment. It is not only that the US, unlike civilized countries, does not provide health care for everyone, essentially free of charge at the time of service (that is, paid for by tax revenues, as well as costing a lot less because of the elimination of the incredible profits extracted by middlemen such as insurance companies in the US). It also provides lousy social services of all kinds, not ensuring, as civilized countries do, housing, food, and education for everyone. These (the “social determinants of health”) are even more important than medical care in creating improved health status. And, while other countries do spend much more money than we do on providing them, the total cost per capita is probably less than what the US spends on health care alone! Of course, much of the spending (particularly on social services and health care for the poor, like Medicaid) is on a state basis; that is why there are such differences between the Massachusetts’ and Mississippi’s in this Commonwealth Fund study. And what are the practices that work? Again, no surprise:

In our scorecard, states with the lowest rates of maternal mortality had:

·       more maternity care providers (Vermont #2, Connecticut #3)

·       fewer women with no prenatal care (Vermont #1, California #3, Connecticut #5)

·       fewer women with no postpartum checkups (Vermont #1)

·       fewer uninsured women ages 19–64 (Vermont #3)

 

It cannot be stated too strongly that public funds should support a public social safety net, not bloat the profits of private companies as they do here in the US! This is most well-documented for the piggish pharmaceutical industry and the entirely unnecessary (indeed, far worse than unnecessary, destructive and evil) for-profit health insurance industry, which I have discussed many times. But it is also the other parts of the health care industry, particularly delivery systems (e.g., hospitals). Yes, the for-profits, hospitals and nursing homes and other facilities, especially those run by corporations. But it is also the ostensible “non-profits”, which do their best to emulate for-profits by doing everything possible to exclude patients without insurance or with Medicaid, pay their CEOs (and other C-suite executives) exorbitant salaries, and channel huge earnings into subsidiaries that actually own or invest in for-profit enterprises! This is documented in Why many nonprofit (wink, wink) hospitals are rolling in money by Elisabeth Rosenthal (Washington Post, July 29, 2024) and discussed by Don McCanne in Health Justice Monitor ‘Not-for-profit care begets profits’. Dr. McCanne cites a study by KFF showing even a program providing “street medicine”, healthcare for the homeless, in California is making money by getting huge amounts of Medicaid funds. Providing health care to homeless people is a good thing, something we need more of. If I had my druthers, I would rather see them making money than huge “non-profit” hospital systems (or of course straight for-profits, although those at least pay taxes), but they shouldn’t be either.

In health care, and in all social service, all the public money should go to providing direct care (OK, maybe with a 2% overhead, like Medicare – but NOT Medicare (Dis)Advantage – has). Zero dollars should go to profits (or “excess” income that can be invested for profit), bloated salaries, and the like.

We have too many people, women and others, dying because of the lack of such care.

 

*Louisiana just put the two drugs used for medication abortion, mifepristone and misoprostol, on its state’s controlled dangerous substances list, like narcotics. So look for LA’s ranking to drop!

In Europe, health care does not bankrupt people. And universal coverage means they get the care they need.

A recent note from a friend of a friend:

‘Here we are in the Pyrenees foothills outside Perpignan [France]. An hour away from the closest ER. X was in the hospital with afib [atrial fibrillation, a heart rhythm disturbance] before we left for France in July and I’m worried about being so isolated. So in Sept he seemed disoriented for a few moments and I was worried so called the French version of 911. I just told them what was going on and they connected me directly with a doctor. They sent an ambulance. The EMTs thought he was OK after checking. But just in case, they SENT A HELICOPTER WITH A DOCTOR from Perpignan. Who also thought he was probably OK. But to be safe they took him by helicopter to Perpignan, arriving in nine minutes. They kept him overnight and let him go the next morning. He’s fine. I had to call them three weeks later to ask for a bill. They emailed it to me. It was itemized: ER, helicopter, two cardiologists, several imaging tests, overnight stay. Total price (for the uninsured): 249 euros.’

Wow! How much is a Euro? Must be like 10, or 100, times as much as a dollar, right? Um, no. Actually, with its recent fall the Euro is just about exactly $1. So $250 for all that? Unbelievable! In fact, if the Euro was worth $100, it would be $25,000, which would still be a lot less than the cost would have been in the US. If you could get that kind of care!

Indeed, that was the situation for this same family earlier…

‘Five years ago X had another chronic problem which has mercifully since been totally fixed. We came here, it started up, and we ended up with five ER admissions, six weeks in private rooms, 3 specialists, transfusions, intensive care, many tests, IV antibiotics etc etc etc. Total bill: about 20,000 euros over 6 weeks. Then back to [hometown in US], one night at [university hospital]: same price.’

What is going on here? It really is unbelievable! Except what is unbelievable, to people in France, or most of Europe, or most countries in the wealthier part of the world, is that we would find their out-of-pocket cost of care surprising. Everyone thinks, to some degree, that what they know, what their world consists of, is pretty much normative, that it is the same for kind of the same people everywhere. In fact, even when they intellectually know that it is not true, it is still one’s instinctive reaction, to think that what is normal for you is normal. Luckily for the French, what is normal for us in the US, in regard to the cost of healthcare, is not normal for them. And, of course, unluckily for us. And this is not a recent change.  It wasn’t even new back on January 21, 2012, almost 11 years ago, when I wrote ‘One thing to NOT worry about: paying for health care -- in France. Or for decades before that. In that piece, I wrote about going to see the film Le Havre and noted that in it a really poor person spends weeks in the hospital and the one thing no one is worried about is the cost. This could never be true in the US.

Doesn’t this upset you? Don’t you think something is wrong here? What is going on????

Sorry.  Of course it does. But, you know, it must be costing someone a lot of money, even in France, or wherever. All that health care, all those hospitalizations, all those tests, do not come cheap.

No, they don’t. But they don’t have to be so expensive. There is incredible markup on the bills and amount paid in the US. Not that anyone actually knows what the price is, or that there is any consistency to it.  US hospitals do have a Master Price List (like “one gall bladder surgery, $X) but it rarely is what is either billed or paid. These hospitals have deals cut with large insurers on how much they will be charged, and pay, on behalf of their customers. Medicare, the government insurance system for the aged and disabled, sets its own rates as to what it will pay (and the private insurance rates are usually expressed in “multiples of Medicare”). Really the only people who might be charged the “list price” are those who are uninsured and poor, those least likely to be able to pay it – although very few of us could pay those amounts! The couple who wrote about their experience in France is obviously well enough off to have spent that time in France, and to have paid their bill, but just being reasonably well off is far from sufficient to be able to pay hospital bills out of pocket.

Let us be entirely clear and simple: The reason US health care costs so much is profit. It is that everyone, everywhere along the line, is taking a cut. The insurance companies, right from the start, huge profits (and salaries to their executives). Hospital systems, huge markups (and salaries to their executives). Pharmaceutical companies, huge markups (and salaries to their executives). Doctors also, especially in some specialties. I could give lots of examples of those specialties with the highest income/work ratios. It is not because we use “too much health care” – indeed, it is really unlikely that any of us (unless a billionaire or a head of state) could have gotten the care that X did in France, and they did that just “routinely”, because it was what they thought was medically the right thing to do.

That, of course, is the other part of this story. It is not just that the charges and costs to the individual were so much less than what they would have been in the US. As a physician friend pointed out “The dollars and cents issue is important. But freeing the medical community to just do the right thing is immeasurable.” Think about that. At each stage, from the person’s wife calling French 911, to the EMTs who came, to the doctors who decided to airlift him to the city, to those who cared for him in the hospital, the decisions that they made were medical, what, in their judgement, was the best for the health of the person/patient. At no point did the cost of the care enter into their decision. Well, I take that back. It may have. But what did not enter the decision was “what kind of coverage does this particular person have? Does it pay enough? Does it cover what we want to do? Have they met their deductible? Can they afford the copay?” This is what you would want for your own health care, and it is absolutely what doctors and other health professionals want to be able to do. Once there was a joke (what today would be a meme) that before doing a procedure the doctor would do a “wallet biopsy”. Today, it is more often the hospital, and it is more likely an “insurance biopsy”. This is crazy.  It is crazy. It is unacceptable. And more important, it is unnecessary.

And the cost of health care per capita is much LESS in France, just as the quality of care is higher (as I cited from the Commonwealth Foundation in my last blog post, Premiums are up, people are dying and insurance companies are making out like the bandits they are, October 25, 2022). Indeed, it is less than half the per capita cost in the US. And in France, that includes everyone; no one is without coverage.

Of course, not foreigners, like those visitors from the US, who had to pay their whole bill themselves with no insurance.  All $250 of it.

Premiums are up, people are dying and insurance companies are making out like the bandits they are

In “Medical debt ruined her credit: 'It's like you're being punished for being sick'”, on NPR October 6, 2022, reporter Aneri Pattani covered the story of Penelope Wingard of Charlotte, NC, and others who had their credit ratings ruined as a result of the cost of medical care. This is bad, but is not as bad as the fact that they could no longer receive medical care. Wingard tells the reporter that "My hair hadn't even grown back from chemo, and I couldn't see my oncologist." After all, the doctors and hospitals want to be paid. In response to pressure from breast cancer advocacy groups, North Carolina had passed a law that temporarily granted Medicaid to breast cancer patients like Ms. Wingard. But then it ran out. As did her money. And her medical treatment. And her credit score plummeted.

What is the worst part of this story? For Ms. Wingard, it is both that she is broke and has no credit, and that she can no longer get treatment for her cancer. For many of the rest of us, it may be that something like that could happen to us or someone we love. For all of us, it is the remarkable fact that we find it unremarkable, that someone could go broke from their medical bills and lose their ability to buy necessary things on credit, and then not even be able to get their needed medical care. It is just the way it is, we think. Awful, and it happens all the time.

Except it is not just the “way it is”. Only here. It is not this way in any other wealthy, or most middle-income, countries. They all have universal health insurance that covers everyone for medically necessary care. Mostly they have had it for many decades. What is remarkable to most people in those countries is that we could possibly think that such a thing is unremarkable, if not exactly “OK”, is the “way it is”, and we are willing to tolerate it. This was the message from the PBS documentary by T. R. Reid “Sick Around the World”, aired in 2008, and covered by me, along with its 2009 follow-up “Sick Around America”, in ‘"Sick Around America": A little bit sickening’, August 5, 2009. In the earlier show, Reid interviews political and health leaders in 6 countries and asks, among other things, how many people in their country go bankrupt from medical debt. In that post, I quote the then-president of Switzerland, ‘a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”‘ Then, and now as we approach the end of 2022, it should be one in the US, and yet we get stories like those of Ms. Wingard. These issues affect many Americans, and as usual are worst for those who are most disadvantaged.

It is “the way it is” in the US because we have chosen to make it so. Actually, it is our politicians who have chosen to make it so, blocking any effort to implement a universal health insurance program, from the 1920s to the time of Harry Truman in the late 1940s (when the AMA was the big opponent), to the 1960s when Medicare and Medicaid were passed and seen as the forerunners of such a program, to the current day. Why? Because of the powerful interests of those who are making money off our current health system, insurance companies and hospitals and other delivery systems (often vertically integrated) and pharmaceutical and device makers, who give lots of money to politicians and wield a lot of clout. They are not only making lots of money in an ostensible “free market” system, but in particular from government programs that they collect public money from. Don’t buy the false idea that “privatization” reduces costs; “administrative costs” are <3% in traditional “government” Medicare but upwards of 15-20% in Medicare Advantage. What privatization does is increase profit!

And, not content with making a lot from Medicare Advantage (a private, for-profit operation that our politicians should not allow to use the name “Medicare” – indeed, there is a bill in Congress now to prevent it – write your representative!), they further game the system by “upcoding”, paying folks whose job it is to make sure that every potential diagnosis and complication is recorded to maximize the amount of (your tax dollar) money that they collect from Medicare. Sometimes this is legal, if outrageous, but insurers are certainly not unwilling to push the legal envelope for more money (‘Cigna received millions of Medicare dollars based on invalid diagnoses, lawsuit claims’, ABC News October 17, 2022 -- and ‘millions’ is an underestimate). And it is assuredly not just Cigna that is guilty; while insurance premiums for Americans have increased 200% in the last decade, United HealthCare last year reported $24B ($24,000,000,000) in profit, more than ever before, an obscene amount, and a completely unabashed example of the fact that what is called the “healthcare” industry in the US is just an enormous profit center for the corporations that control it.

You want to know why we spend 2-3 times as much as any other wealthy country on “healthcare” and yet have so much poorer outcomes, shorter life expectancy, greater infant mortality, higher rates of “deaths of despair”? (‘Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries’, Commonwealth Fund). This is the reason: the money is going to corporate profit, not your health care! If it were going to your healthcare, our outcomes would be better. But then they would not be making so much money, and donating so much of it to our (or maybe it is “their”) politicians.

Oh, maybe you thought that was the end. That insurance companies are raising our premiums, denying needed healthcare to sick people, making billions of dollars in profit, and corrupting our political system to ensure that it continues, was bad enough. And convincing you to shrug your shoulders and think “it’s sad, but that’s the way it is” when someone gets very sick, maybe dies, and goes bankrupt in the process. But, you know, that’s not enough for them. There is one more step: convincing you – and probably more important, the politicians – that it is not their fault that US health care costs so much. It is not the $24B in profit made by United. It is not the scamming of Medicare done by Cigna, or the entire Medicare Advantage and Direct Contracting Entities (DCE) programs that funnel public money into their pockets. No, no, it is YOU! As Wendell Potter, a “reformed’ health insurance executive, reports in ‘Corporate health insurance consultants blame high medical costs on our "bad habits" and "overuse" of system’ they say it is OUR fault for using too much care. Like, you know, going to the emergency room with chest pain, and sometimes it isn’t a heart attack (bad you!). Or, like Ms. Wingard, wanting to be treated for cancer. Or maybe even going to the emergency room when we are only sick, not dying, because we can’t get an appointment for the doctor.

It's not true, by the way. Europeans are hospitalized more frequently, have longer lengths of stay, and use the doctors at least as often. Their outcomes are better, especially when the health of the entire society is considered (we have a way of fudging this by only considering those people who were actually able to get care), and they pay a lot less. No, it is the profit and “administrative costs” of the health insurance companies and healthcare corporations.

Apparently buying into the idea of “incrementalism”, our politicians for the last 60 years have given us limited programs to help limited groups of people, at least somewhat. Seniors, disabled people, sometimes children, sometimes programs like the North Carolina one that paid for Ms. Wingard’s cancer treatment specifically because it was breast cancer (until, of course, it didn’t). This is NOT the way to go to get universal health care. The ACA (Obamacare) included the option for states to expand Medicaid to the less-than-desperately-poor and some did and folks in the other states are getting sick and dying.

No. We need a universal, comprehensive, EVERYBODY in, NOBODY out, health insurance system, government run or tightly regulated so there are not obscene profits. Like improved and expanded Medicare for All. Now.

 

Are primary care practices prepared for complex patients? Is this even the right question?

The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, "Et qui vendit pellucidum", a recent blog post by my friend Dr. Allen Perkins).

One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).

A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”[1], published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.

The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).

The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.

Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”.  Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.

Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.

As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.

A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.

It is also the way we need to go in the US.

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[1] Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018

The role of Primary Care in improving health: In the US and around the world

At the Family Medicine Midwest conference held recently in Milwaukee, the first day’s plenary speaker was Richard Roberts, MD, from the University of Wisconsin. Dr. Roberts has a distinguished history as a health services researcher and leader in Family Medicine, having been president of both the American Academy of Family Physicians (AAFP) and the World Organization of Family Doctors (WONCA). He has extensive experience in international health, and is knowledgeable about the health systems – and their results – in countries around the world. And he continues to practice family medicine.

Some of the issues that Dr. Roberts discussed involve the health care system, and, drawing from the important work of the late Dr. Barbara Starfield, emphasize the importance of primary care to improving the health of a population. I have written about the disproportionate emphasis of medical education on hospital care, advanced disease, and high-cost rescue interventions which often fail to rescue and frequently cause complications, rather than on primary care, prevention, and early diagnosis and treatment. Dr. Roberts reminds us of the “Ecology of Medical Care” (referring to the

setting in which health care takes place), done first by Kerr White in 1961[1] and replicated by the Graham Center of the AAFP in 2003[2] with remarkably similar results. In a community of 1000 adults, in any month about 800 have a health problem or injury, 217seek attention from a doctor, 8 are hospitalized, 5 see subspecialists, and 1 or less is admitted to an academic medical center teaching hospital, which, of course, is where we train most medical students and residents, and where they get a skewed view of the prevalence of disease. They begin to see unusual or even rare things as common, and develop habits of ordering tests that are perhaps appropriate in that setting, but dramatic overuse in ambulatory practice.

In 2005, there were 34 million hospital admissions in the US, but almost 1 billion office visits. Of those, about 53% were to primary care physicians. While much is made of the increase in emergency department usage, from 1995 to 2005 ER visits were up 8% while primary care visits increased 22%. As Roberts notes (medical students should cover their ears!) primary care doctors comprise about ¼ of the physician workforce but see more than ½ of all patient visits and earn about ½ the income of subspecialists (and this is average; a much smaller fraction of the income of the most highly paid subspecialists).

Internationally, the same trends are noted. Countries with a higher “primary care score” (which largely measures the percent of the medical workforce in primary care) had lower rates of premature deaths than those with low PC scores in 1970, and over the last 4 decades, while the rate has gone down in both groups, the gap between them has widened. In an unintended “natural experiment”, the Asian economic boom of the early 1990s allowed Indonesia to greatly increased health spending, mostly in primary care; that nation saw a 70% improvement in health status in all provinces. With the collapse of that “bubble” in the late 1990s, spending on primary care went down, but not on hospital care in the big cities. This was a result not of Indonesian government decisions, but rather of the international community through organizations such as the World Bank saying “your economy is worse, but you need health care – here’s money … to build hospitals”. But health status dropped in most provinces. Not the best use of resources!

In the 1990s, Shi studied socioeconomic, environmental, and health system characteristics of US states and their relationship to health status (mortality, lifespan, deaths due to heart disease and cancer, neonatal mortality, and low birthweight). Access to primary care was the strongest predictor of greater lifespan and was second (to living in an urban area) for lower mortality rates, even ahead of education. Number of specialists and number of hospital beds were far down the list – indeed they were negative predictors![3] None of the changes in the health system since that time are likely to change this; indeed, the increase in specialists, technology, and hospitalizations have probably increased it.

What is it about primary care? Why does it make so much difference. Starfield’s work identified the fact that nations and regions with high levels of primary care have greater self-reported health status and fewer health disparities, and that the presence of primary care tends to mitigate the negative impact of income inequality.[4] This group also demonstrated that an increase of primary care physicians of 1 per 10,000 (20%) physicians decreases mortality by 40 per 100,000 (5% fewer deaths), and 1 per 10,000 (33%) more family physicians decreases mortality by 70 per 100,000 (9% fewer deaths), while an increase in specialists of 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths). [5] Dr. Roberts notes 4 features of systems with higher primary care to specialist ratios that might affect this: 1) when there are too many specialist and not enough primary care doctors, specialists may try to manage conditions outside their specialty in which they are not knowledgeable; 2) prevention and early detection save more lives and extend life more than intervention late in the disease process; 3) there is excessive utilization of procedures when there are too many specialists (supply drives demand rather than vice versa) and these often have risks; 4) the more “handoffs” there are between doctors caring for a patient, the more that care begins to resemble an elementary school game of “telephone”, where the final message heard is very different from that which began the communication.

The fact that family physicians specifically seem to improve population health status more than primary care physicians taken as a whole is apparent in the data, but the reason has not yet been identified by studies. Dr. Roberts postulates that it has to do with caring for multiple family members, and using that information to improve their care, such as when a mother’s issues are addressed at a visit ostensibly limited to caring for her child. Primary care (and possibly especially family physicians) acts to achieve all aspects of what has been identified as the “Triple Aim” of health care: greater access, lower cost and higher quality.

Primary care doctors, and especially family physicians, are doctors of “first and last resort”. They care for pregnant women and deliver their babies and care for their children as well as the other adults in the family. They tend to the “grandparents”, older adults, and manage the often complex interplay of multiple chronic diseases. They provide acute care and preventive care and are aware of the individual’s beliefs and preferences and those of the family, and the dynamics that exist between them. They care for people at the end of life, right through the end, not just until “there is no more to do”, and they remain there for the survivors.

The US could do a lot better. We need a health system that is more grounded in primary care, and we need a health system that provides access to everyone. What we don’t need is folks in Congress are committed so committed to preventing that access they will shut the government down!  Another conference speaker, Dr. Cynthia Haq of the University of Wisconsin, quoted the Ethiopian Minister of Health, with whom she had recently met. “Only in the United States,” the Minister said, “could there be discussion about whether access to health care was a human right or not.”

Oh, my. He’s right. I sure wish he were not.

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[1] White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.

[2] Green, LA et al., “The ecology of medical care revisited”, N Engl J Med 2001; 344:2021-2025June 28, 2001DOI: 10.1056/NEJM200106283442611

[3] Shi L, "Primary care, specialty care, and life change", Intl J of Health Service,1994; 24(3):431-58

[4] Starfield BA, Shi L, Macinko J, “Contribution of Primary Care to Health Systems and Health”, Milbank Quarterly Sept2005; 83(3):457-502. DOI: 10.1111/j.1468-0009.2005.00409.x

[5] Shi L, et al., “The Relationship Between Primary Care, Income Inequality, and Mortality in US States, 1980–1995”, J Am Bd Fam Med, 1Sep2003;16(5)412-422. doi: 10.3122/jabfm.16.5.412.