We need more generalist physicians. And a new health system so that they can be effective.

We don’t have enough primary care physicians in the US to properly (or, often and in many places, even improperly) care for our people. We all need a primary care doctor, and some of us need specialists. But rarely does a specialist have the time, interest, or expertise to manage all of your problems, and also do the recommended preventive work. Unfortunately, primary care physicians rarely do either, especially when it involves managing the care delivered by many different specialists, who can be unaware of what treatments the other is recommending and of how it might conflict with treatment they are giving. Doing this properly takes a lot of work and time.

For example, you mention to your cardiologist that you have knee pain. They say “I don’t do knees; here’s a referral to an orthopedist”. They’re done. If you go to your primary care doctor, they will examine you, try to figure it out and maybe treat it. But if they refer you to an orthopedist, they will follow up, read the report, look at the x-rays, read the recommendation, and try to explain to you what it all means. In short, a specialist referring to another specialist saves time and work; a primary care doctor referring to a specialist generates more work for themselves.

But there are not enough primary care doctors to do this, and those that exist are not given sufficient time by their employers (most are employed by hospital systems or large groups, often owned by private equity) to do it right. Because – and this is the most important thing – these hospital systems and especially private equity are, like insurance and pharma companies, in the business of making money, and only incidentally providing health care. Yes, many doctors are also interested in making money, but this is not their only or primary concern.

So, because most doctors are employed, and because primary care doctors may work much more for much less money, we have a dramatic shortage of primary care doctors in the US. A recent issue of Your Local Epidemiologist describes this in some depth.

One approach to primary care is that which Sweden has adopted, as documented here by the Commonwealth Fund.

Sweden is aligning primary care access goals with physician workforce policy more explicitly. Rather than treating physician training as separate from care delivery, Sweden is using workforce policy as a tool to strengthen continuity, accessibility, and person-centered primary care. To support this goal, the Swedish National Board of Health and Welfare analyzed primary care workload and physician capacity, established a benchmark of one primary care physician per 1,100 residents, and issued recommendations to guide regional workforce planning toward that target.

The Commonwealth Fund notes that

The United States faces a similar problem. Although physician training strongly influences where physicians ultimately practice and what specialties they choose, federal graduate medical education (GME) financing remains largely tied to algorithms based on hospital funding patterns established decades ago. The Centers for Medicare and Medicaid Services lacks authority to measure workforce outcomes associated with the nearly $21 million in Medicare funding that supports physician training. The result is a system that often produces workforce outcomes misaligned with patient needs, specifically not enough primary care physicians, general surgeons, and psychiatrists.

Commonwealth adds “Sweden’s recent reforms suggest a different model: define national access goals first, then align workforce policy around them.”

What a novel idea! Imagine figuring out what you are trying to achieve and then designing a system of achieve it! This is completely different from how health policy, including (or perhaps especially) physician supply and makeup is done in the US. (Well, except for for-profit companies who know what their goal is – make more money by any means necessary, which is never providing you with the best, most comprehensive and effective, or accessible, healthcare.) The system we use is to … do the same old thing. Pay subspecialists more, allow students to choose which specialty they want, and expect that somehow enough will choose primary care, despite the fact that they will make far less and often (not always, depending on the other specialty) works more, will almost be always employed by a large hospital system or group practice owned by private equity, and be on a hamster wheel of “productivity”, which means they cannot see enough patients, cannot deliver adequate care to the people they do see, and for themselves achieve limited professional satisfaction in having the control necessary to influence positively the health of their patients. 

As I have written before (e.g., Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013; Pay primary care more: Kennedy may be getting this one right!, July 23, 2025 ), there is no mystery on how to change the income levels of primary care physicians relative to subspecialists. The Medicare payment “pie” is divided up between specialties mostly on the recommendations of an AMA-appointed group of physicians called the “RUC”, which is dominated by subspecialists. CMS, whichadministers Medicare, doesn’t have to follow the RUC’s recommendations, but usually does. And the RUC’s makeup of about 15% primary care physicians guarantees that primary care will be underpaid by Medicare. And, since almost all insurance company reimbursements are based on multiples of Medicare payment, this translates to the whole system. CMS could set up, or require the AMA to set up, a RUC that was, say, half primary care doctors!     

A word on the term “primary care”. While it has become the standard phrase in the US, and we can’t get away from it, it is not a great one. It was popularized by internists (adult medicine doctors) to distinguish those more properly called “general internists” from their internal medicine brethren who did mostly hospital work (“secondary care”) including intensive care (“tertiary care”), and then expanded to include general pediatricians and family physicians. Of course, family physicians are mostly all (90%) in what is now called “primary care”, and they (or the also commonly used “general practitioners”) are the mainstay of outpatient care physicians for the populations of most countries. Family physicians differ from other “primary care” physicians in that they are trained to provide comprehensive care for people of all ages, with all problems (referring when necessary) across the lifespan, including caring for children, old people, delivering babies, caring for folks in the hospital, in nursing homes, and doing lots of different procedures.

Unsurprisingly, it is hard to find even family physicians doing all these things now, except sometimes in rural areas where there are fewer physicians in other specialties. It has always been true that the privileges granted to family physicians have been largely determined by how much other physicians can make doing that work; many will be “first assistant” surgeons (fairly well paid) except when their communities have a glut of surgeons who “need” the work = income. Many years ago, it was discovered that only about 10-15% of graduating family medicine residents in Texas were interested in delivering babies in rural Texas; however, this was compared to 0% of OB-Gyn residents!

So let’s start with identifying what we want to achieve: enough primary care physicians, distributed broadly enough across the country in rural and urban areas, for every single person to have one. For those primary care (or family, or generalist) physicians to be paid enough relative to subspecialists that students are attracted to the field. For them to have enough time budgeted to manage complex problems and even more complex interactions between patients and other doctors. This is especially a need for older adults, who are most likely to be seeing multiple specialists for multiple problems. Relying on ERs or Urgent Care is a very poor and inadequate alternative.

That requires a complete reworking of how our health system functions. Covering everyone, such as by the improved and expanded Medicare for All system called for by the S. 1506 and HR 3069 bills, is an absolutely necessary part of this, but is not alone sufficient. We also need to restructure physician payment to encourage enough primary care that people can easily access it and it can be effective, implementing completely Starfield Four Pillars of Primary Care: [first] Contact, Continuity, Comprehensiveness, and Coordination (Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992). If ANY of these are missing or incomplete, we have an inadequate health system – as we in fact do.

No messing about at the edges. No "reforms" that reform little. No saying we cannot afford universal health care, something every other developed country does, because our insurance companies need to make huge profits. No denying the need for an immediate steps to ensure an adequate primary care workforce because we don’t want to pay subspecialists less.

This must happen now, happen yesterday. There is no morally acceptable alternative.

 

                                       

Health Insurance is not Healthcare: Everybody in, nobody out!

 I have long advocated universal health insurance, recently in the form of Improved and Expanded Medicare for All. What “Expanded” means is obvious – EVERYONE would be in it. As the late Quentin Young, MD, was famous for saying “Everybody In, Nobody Out!”. That should be simple to understand. The “Improved” part means “not having the limitations of current traditional Medicare”. This means also covering dental, vision, hearing, and long-term care. And, most important, to eliminate the 20% of the amount that Medicare approves that patients are responsible for paying for hospitalization (Medicare pays 80% of approved hospital charges), or at least capping the dollar amount (not %) that people have to pay out of pocket. More detail is presented in the Physicians’ Proposal by Physicians for a National Health Program (PNHP), and is essentially what is proposed in the Medicare for All act, HR 3421, sponsored by Rep. Pramila Jayapal (D-WA) in the House, and the companion Senate Bill, S. 1655, sponsored by Sen. Bernard Sanders (I-VT).

I would like to address several important issues about why EVERYBODY IN, NOBODY OUT, expanded coverage for essentially all medical care, and the different between having health insurance and having health care. First a quick review of some of the important places where health coverage was expanded, just for background.

When there was a limited amount that doctors could do for people, folks accessed medical care with cash (or chickens). When hospitalization and surgery became effective for many conditions, insurance like Blue Cross/Blue Shield were established, mainly by surgeons. These were for a long time non-profit. After WW2, because the federal government implemented wage and price controls, even though there was a labor shortage companies could not compete by paying higher wages so benefits, like health insurance, became attractive. This was embraced by organized labor, which could exhibit such insurance as a member benefit. In 1965, Medicare was implemented to cover aged and disabled people, a huge advance. Medicaid, a program for low-income people who could not afford health insurance, was also a huge advance, but as a federal/state partnership, who and what it covers varies a lot from state to state. The ACA passed in 2010 (Obamacare) further expanded coverage by making health insurance affordable for many more Americans. This is the really short course.

 

As can be seen in the graphic (from Statista®) the number of uninsured people in the US has, as a result of the programs above, dropped dramatically. There are, however, 3 big problems that continue to exist. First, 25 million is a lot of people without insurance. Second, having health insurance, in the current chaotic system, is not an all-or-nothing thing. Many “insured” people have poor quality insurance, with high deductibles, high copays, caps on coverage, and high rates of denials by their insurance for treatments recommended by their physicians. Even people with “better” (and often more expensive, and likely paid in part by their employers) health insurance find themselves confronting these same trends with costs often making getting care unaffordable. The key lesson here is “health insurance is not healthcare”; if the care you need is unavailable to you because it is unaffordable despite having some form of insurance your health is not improved. This is what I will mostly talk about below.

Third is what changes will happen with the new Trump administration. We cannot know for sure what it will succeed in doing or even try to do, but it won’t be good. He and his advisors want to get rid of the ACA. They want to further privatize Medicare by moving more people into Medicare Advantage plans, which are private insurance plans paid for with public money that can and do often deny you care. (see Such a deal! Insurance companies keep your money and deny you care! How can I get in on that?, Oct 28, 2024.) If you want to get more information, check out the Project 2025 proposals for health care and health insurance.

So, let’s get back to the second, that having health insurance is not the same as having health care. This should also be obvious, but apparently it is not to a lot of people, including politicians, pundits, and health economists. For most things we buy, we trade off quality and price, usually assuming that higher price will lead to higher quality. With health insurance, it is sort of that way, but unfortunately the price is so high that many people buy the lowest cost (and lowest quality) because that is all that they can afford. It is why so many people have high-deductible plans that, when they need to use them, are not actually useful for obtaining health care because the deductibles and co-pays are so high. It is why the lowest cost ACA plans are the most popular and deliver the least. And it is one of the main reasons why so many seniors have opted for Medicare Advantage (MA) plans rather than traditional Medicare (TM). The entry cost is lower, they cover some things TM does not (like glasses and hearing aids and dental) and it does not require purchase of a Medicare Supplement (Medigap) plan to cover the 20% of approved hospital charges that TM doesn’t pay. But when folks get sick, they may discover that the MA plan does not cover the hospitals or doctors they want and that, because they are private insurance plans and not, in fact, Medicare, they can and do deny coverage for lots of things. Oh, well. You want a lot of detail on how bad it is? Look at the Commonwealth Fund’s Biennial Survey, “The State of Health Insurance Coverage in the US”.

Why do we demand such premiums, deductibles, and co-pays? A lot of health economists have used the term “skin in the game”, implying that if people have to pay some of their own money they won’t “over-use” health care, which drives up the cost. This analogy to gambling is flawed, and wrong. There is no evidence that “over-use” is a major driver of health care costs, either in the US or, more importantly, in other countries where the direct costs to patients are non-existent or very limited with low caps on the maximum that people can spend out of pocket. It is a theoretical belief not supported by the data. And politicians, pundits, health economists, and newspeople are employed, usually with relatively high incomes, and what seems to them anecdotally to be “not so much” (a few thousand dollars?) is so high for many Americans that they forgo health care altogether.

The cost of US health care is indeed extremely high, but it is not because people over-use services. Physicians often over-use (over-order) services because they can see the benefit but not the cost, because they may make money from procedures and even more from their use if they also own, say, the imaging center, and because they fear lawsuits if they do not. But most of the excess cost of US health care compared to other countries (many of which actually use more health care per person than we do, in terms of things like hospital beds per population) is the excessive administrative cost and profit on the part of health insurers and large care providers like hospital systems.

What can we do? Well, we can eliminate for-profit insurance companies, or regulate the heck out of them so that, as in countries like Switzerland, they have to provide the same set of benefits at the same price, cannot make a profit, and have to compete on – get this – customer service! We can have one single-payer plan, Medicare for All, improved to cover everything and expanded to cover everyone. In the meantime, we can at least cap the out of pocket maximum people have to pay to, say $1000. How could we fund it? Let’s start with the $590B in overpayments to Medicare Advantage plans!

A year ago, Levitt and Altman wrote about the complexity of the US healthcare system (Complexity in the US Health Care System Is the Enemy of Access and Affordability, JAMA Health Forum), and included this:

 “Yet, any push for health care simplification inevitably clashes with commercial interests. The health insurance system is structured to simultaneously maximize profits, control costs, and serve consumers, which are competing goals that add to the challenge of simplifying it.” 

OK. Can any decent person even consider that the value of “maximizing profits” should have any weight compared to “serve consumers”? It might be the defining question as to whether one is a decent person!

Finally, though, we need a system to cover everyone, well, so that they can really get healthcare.

EVERYBODY IN, NOBODY OUT!

 

Being blown off by health care can cost you your life...

Dealing with corporations is hard. Robots answer your calls, but not your questions. They are programmed to give you the information the company wants you to have, not the answers you need. It is very difficult to ever find a “monitored” email address to write to. It is like they don’t want to hear from you (except in the ubiquitous and totally structured “tell us how we’re doing” requests). Charges (as I experienced recently) are posted to your credit card immediately. Refunds, even when they agree to one, can take 45 days (by policy).

People, on the other hand, are almost always good and helpful. If you have the time and patience and willingness to scream “representative” at the phone often enough to actually get one, they mostly are polite, empathic, and usually resolve your problem (unless such resolution is prohibited by company policy). At least they answer your questions. It is amazing but not surprising that companies make it so hard to get to them. After all, they may help you out. Which is not what the company wants; they want your money and you be gone! Robots are also cheaper, thus increasing profit (and unemployment).

And so it is with healthcare. In which case it can be a disaster. I don’t mean that the waste of your time and money with other corporations is ok, or even just bad, or that it cannot financially be a disaster. But in health care we are talking about the health and even lives of you and your family. If you can’t get hold of your health care providers, you can’t get seen and cared for, or get the information that you need to do what you need to do, or to be seen elsewhere. This is, again, not the fault of or the result of the actions of the actual people who care for you, who if you can get in to see them or speak to them on the phone are usually very helpful. It is the fault of the system that is structured to prevent you from getting to them, because less use by you results in more profit for them.

That, of course, is at the provider level. At the insurer level, we enter a whole new region of Bizarro World. You get insurance. You find a provider. You see your provider. They recommend a treatment plan. You agree. Now the insurance company, which has a policy requiring “prior authorization” for virtually everything, denies payment. There may not be a good, or even any, medical reason for denying payment, and, if you appeal, they may pay because, after all, there is good medical reason. But denial as a first line response is great -- for them. Most people don’t appeal. They often don’t know that they can, or how to. So, for the insurer, problem solved. Of course, their problem was that they were going to have to pay money, and now they don’t. Your problem? Not solved. And your problem was your health, treatment for your disease. Whoops.

Prior authorization is an effective tool used by insurers to not pay for your care. It is more ubiquitous in “managed care” plans (HMOs, PPOs) than in open insurance plans. Of course, the latter are getting much rarer. It is cheaper for your employer to enroll you in a managed care plan. (Noticing a theme here?) Medicaid the (almost always dreadfully inadequate) public state/federal partnership for covering the poor is mostly (41 states including DC) turned over to managed care. One of the last bastions for fee-for-service, Medicare (the federal insurance plan for the aged, blind, and disabled) is quickly moving in that direction, with over 50% of Medicare patients not enrolled in actual Medicare but rather in “Medicare Advantage” (sic) programs, essentially private HMO-type plans paid for with Medicare funds. Now Medicare patients too can experience the advantages of managed care (like eyeglasses and gym memberships) as well as the disadvantages (like limited provider networks and denials of payment when you actually get sick).

A lot of the burden on privately-insured patients is demonstrated in research by Sukreth A. Shashikumer et al. in Financial Burden of Health Care in the Privately Insured US Population,
JAMA Internal Medicine, May 28, 2024, and summarized in the Health Justice Monitor.  

Among low-income families, mean total health care spending was $3163 in 2007 and $3247 in 2019. Low-income families’ medical burden was 23.5% in 2007 and 26.4% in 2019.  Among higher-income families, mean total health care spending increased from $4071 in 2007 to $5239 in 2019. Higher-income families’ medical burden was 5.4% in 2007 and 6.5% in 2019.

It’s bad for everyone but is, as always, worse for lower income people. This is also described in detail in a recent article by the Associated Press’ Tom Murphy, “Being a patient is getting harder in a strained and complex US health care system” (June 2, 2024), which describes the direct negative impact of insurance company denials on people’s health. The article discusses how some coverage for patient navigators helps, but the core problem is that is in the interest of the insurer to not spend money. Some MA plans like to say that they are enhancing health equity by covering a lot of low-income and minority people. Of course, this is only because the up-front costs are less. Those people pay when they get sick not only with dollars (co-pays, deductibles) but with their health (limited networks, denial of care).

And the majority of Medicaid recipients are children, and they are not immune from being denied care by their insurance companies, as revealed in a report from the General Accounting Office (GAO) and described by Wendell Potter in his “Health Care Un-covered” substack. It reports that insurers use both prior authorization and denial of payment for services, called EPSDT (Early Prevention, Screening, Diagnosis and Treatment) that the law REQUIRES be provided!

Contrasting traditional (real) Medicare with Medicare Advantage is useful here. You pay into Medicare your whole working life. When you are old enough and receive it, traditional Medicare pays for the services you receive (with some important limits, mainly only 80% of hospitalizations, requiring a Medigap plan). Medicare Advantage however, receives the money for your care from Medicare up front. Their incentive, then, is to keep it, by spending as little as possible on your care. That’s it in a nutshell. It is described in more depth in the report from Physicians for a National Health Program (PNHP), “Taking Advantage: How corporate health insurers harm America’s seniors.”

It is awful how badly corporations treat people. The laws and regulations need to be changed, to require them to provide the goods and services they have been paid for, and to make access for concerns or complaints, including access to actual people, easy. But completely different rules need to be in place for healthcare. If I can’t get through to most companies until Monday, I can live with that. If my credit card company keeps me going through the hoops on the phone for a half hour or more before I can talk to a person, I am only wasting time. But if this happens when I am trying to access health care, I can get very sick or die! Waiting 6 hours to be seen in the ER is not the answer. Neither are prior authorization, denials, and delays, for sick children, vulnerable seniors, poor people, or any of us.

What can we do? Write and call our congresspeople and demand that they eliminate profit-making insurers from healthcare. Perhaps some are not stupid (believing what lobbyists tell them, such as that Medicare Advantage increases equity) or corrupt (gleefully accepting those lobbyists contributions) and actually care about the health of their constituents.

Tell them to sign on to the Improved and Expanded Medicare for All bills in the House (Pramila Jayapal and Debbie Dingell, primary sponsors) and Senate (Bernie Sanders), and to sign the Patients Over Profits pledge being promoted by National Nurses United and other organizations.

Or you won’t vote for them.