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!

Why don't we spend more on public health? It is harder to see the bullets we dodged -- and then there is profit.

“It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?”  (New York Times, May 28, 2018). Actually, this is a terrific question. As so often, it is complicated. Let’s start with the benefits that authors Aaron E. Carroll and Austin Frakt describe. First, there are vaccines. They eliminated smallpox and virtually eliminated polio in the United States. They have dramatically reduced the rate of common childhood illnesses including measles, mumps, rubella, chicken pox, and Hemophilus influenza (H. flu) infection. They have the potential for essentially wiping out cervical cancer through immunization against HPV, and liver cancer (as well as many forms of chronic hepatitis and cirrhosis) through vaccines against Hepatitis B.

A huge public health intervention is making our environment safer. This means having good sewage and clean water, and lead-free gasoline and cleaner air. These changes have saved far more lives, and improved health much more, than all of the individual medical care interventions combined. If you have traveled abroad, especially to less developed countries, you know how important these are. Indeed, better sanitation, as well as better surveillance and treatment, have dramatically reduced other infectious diseases that were once terribly feared, notably tuberculosis. And inspection of our food supply, restaurant and otherwise, are another very important part of public health.

The other big public health measure is education. Of course, education can be and is provided to individuals by health professionals as well as populations via public service education, but it is major nationwide public health efforts that have made a big difference. These include the huge decrease in cigarette smoking, and the greater safety of automobiles and their exhausts. Cigarette smoking used to be ubiquitous (see any WW2 movie) and in what would shock young Americans today, widely practiced in restaurants and even college lecture halls. Today that is unimaginable, and smoking in most places is aberrant, with less than 15% of adults currently smoking and most of those trying to quit. Car accidents are still a major cause of death and injury, but deaths from cars are way down. Almost none of this is related to people driving more safely and almost all of it to safer design of cars (think seat belts, air bags, engines that collapse down instead of back in a collision) and roads. Lead poisoning of children is way down in most places in the US thanks to lead being banned from gasoline and paint.

There are still many challenges on the public health front. Reducing the rate of chronic diseases though education around eating huge numbers of empty calories still have a long way to go. The terrible infectious disease epidemic of recent decades, HIV, has been greatly reduced by treatment, but until there is a vaccine, high-risk sexual behaviors persist. The opioid epidemic is killing more and more people, and it is only through societal approaches that this is going to be reduced.

The epidemic of gun death is not abating; many studies and articles in the press have recently discussed the increase in the suicide rate, often prompted by recent high-profile suicides such as those of Kate Spade and Anthony Bourdain (How Suicide Quietly Morphed Into a Public Health Crisis; 5 Takeaways on America’s Increasing Suicide Rate, ). While neither Spade or Bourdain used a gun, guns are the cause of death in at least half of suicides, and suicide far exceeds homicide in terms of numbers of gun deaths. Those who believe it is not the availability of guns that causes deaths from both causes, and other methods could be used to kill oneself or others, are simply wrong. Easy availability of guns, far more effective and efficient at killing oneself or others than any other method, absolutely has been demonstrated to increase both homicide and suicide. Suicide by gun is over 90% effective; by drugs less than 5%. “Successful” suicide rates are far higher in high gun states (e.g., Montana) than in low-gun states (e.g., Massachusetts). Homicides are also more common where guns are at hand. And, in regard to school and other mass shootings, while you can kill someone with a knife or a baseball bat, but it is hard to commit mass murder with them.

So, why do we not spend more on public health? Why do we spend so much more on what is, from a societal point of view, much less effective individual health interventions, and less than 5% of that on public health? One reason, of course, is that when each of us is sick, we (usually) want treatment, as much as possible, especially if there is a chance that it could cure us, or at least ease our suffering. This is understandable, and it is tied to the fact that we have much greater awareness of treatment of something ailing us (curing our infection, relieving our pain) than of not having disease because of the presence of public health practices. As I would tell students, how often do we wake up thankful that we do not have cholera because we have a clean water supply? Indeed, when we find that the water in Flint, MI, is contaminated with lead, we are shocked because we assume our water is safe; when we find an E. coli outbreak from a restaurant, we are shocked because we assume our food is safe.

There is also, unsurprisingly, the issue of the money that to be made. The provision of public health is rarely a big profit center, and it is usually, therefore, done by government – local, state, and federal. Individual health care, however, is a huge money-maker for insurance companies, hospitals, doctors, pharmaceutical and device manufacturers, nursing home companies, and on and on. All that money – over $3.3 TRILLION by recent estimate -- spent on your and other individuals, while it may (or may not) have a salubrious impact on you, is going into someone’s pocket. On the flip side, public health interventions often reduce profit, especially when they are very effective. The struggle against tobacco, which killed more people than any other cause by far, was fought long and hard by the tobacco companies (currently now plying their wares in the less-developed world).Each of the changes to cars that led to the great increases in safety was fought by the industry. Today, we continue to see tremendous opposition to rules that make our environment (air, water) clean and safe; sadly, under the current administration, many of these rules are being rolled back, which will absolutely decrease our society’s health.

I guess I also need to address the people who believe that vaccines are unsafe. They are a major threat, and presumably haven’t seen children dying of measles, of the suffering of chicken pox and mumps, of the morbidity from H. flu infections of the middle ear (my students have never seen it!) or deaths from H. flu epiglottitis. Yes, there can be minor side effects from some vaccines, but the benefit is overwhelming.

Finally, as always finally, it is the poor and disenfranchised who suffer the worst. While sometimes we have the perverse satisfaction of outbreaks of vaccine-preventable diseases in well-to-do communities, anti-vaxxers unconscionably campaign in immigrant/refugee communities telling people to not vaccinate their children. The poor and minority city of Flint suffers a poisoned water supply. The oldest, cheapest houses are likeliest to have peeling lead paint and be located near polluting factories and dumps. Tobacco and junk food manufacturers advertise most heavily in minority neighborhoods. And, of course, the murder rate is highest in poor and minority communities.

Good medical care for individuals is valuable when it is needed, and could be less expensive. Public health measures are even more valuable and cost-effective. We need to increase the money and effort spent upon public health interventions, and certainly not scale them back.

Benjamin Franklin said an ounce of prevention is worth a pound of cure. It’s true, and is a great argument for greater investment in public health.

Primary care, specialty care: what about health?

Three “Perspectives” in the September 6 issue of the New England Journal of Medicine address different, but clearly related, aspects of the transformation of health care. I have previously discussed one of them, “Becoming a physician: the developing vision of primary care" by Barnes, and Comfort in Social determinants key to the future of Primary Care (September 22, 2012). The two others are "What business are we in? The emergence of health as the business of health care"^[1], by Asch and Volpp from the Wharton School of the University of Pennsylvania, and "From Sick Care to health care -- re-engineering prevention into the US health system" by Marvasti and Stafford.^[2] Taken as a whole, the three provide some significant insight to the current US healthcare delivery system, the changes that need to be made in it, and the way we will get there.

Asch and Volpp discuss the need to shift from "what can we produce" (health care) to "what do people want" (health). They use the parallels of the failure of major industries (railroads in the last century; Eastman Kodak in this) to make this distinction. Each of those industries made the mistake of confusing what they produced with what people wanted when they bought their products. Thus, railroad companies provided railroads, when customers wanted transportation of goods and people; when alternatives (trucking, air) became available they were unable to adjust (although in Europe they did a pretty good job). Similarly, Kodak made film when what people wanted was to store images of their lives. Asch and Volpp do not mention that the ad agencies got this right (“we create memories”) but the corporation did not move into the digital age early enough and, last year, went into Chapter 11 bankruptcy.

The “health care” industry provides, at best, health care, but more often just medical care, and most especially disease care. People seek it out because it is what available; what they want is health, to not be sick, in pain, disabled. This is of course why “mainstream” medicine is not the only source of treatment people seek. It explains the allure, and extensive use, of products of the “alternative care” industry, which ranges from degreed practitioners like chiropractors and naturopaths to long-used herbal and other cultural treatments dispensed by various methods (botánicas and the Internet), to Eastern medicine such as acupuncture, to religious rituals including American Indian healing, Catholic exorcisms, and the rituals of Santeria, Candomblé, and Voodoo derived from Africa, to straightforward quackery. “Integrative medicine” is an effort by traditional western medicine to employ many of these techniques and traditions. While we probably would actually prefer the diagnostic and treatment magic of Star Trek’s doctors, we’d certainly like the magic pill, elixir, injection, herb, or prayer that would heal all our ills – preferably with no real or sustained effort on our parts, and without side effects. Interestingly, while “alternative” medicine is seen as more “holistic”, it is in fact often more biologically reductionistic, using interventions (e.g., enemas, diet changes, supplements) to cure social and psychological problems (see my 2005 piece “Towards a definition of holism” in the British Journal of General Practice).^[3]

Perhaps this is all “quackery”, or just some of it is and others are not. In mainstream American medicine, something doesn’t become a real disease until there is a test for it – or better yet a drug for it – thus the medicalization of many things that people have experienced as part of the mortal coil for thousands of years. Some things that were accepted as “part of life” (and death) are now diagnosable and treatable; others might be in the future. But those of us in the “health care” industry need to understand that folks will only buy what we are selling if it is, on the whole, the most effective way for them to get what they want: health.

Marvasti and Stafford discuss the need to change from a system designed to treat acute conditions and acute exacerbations of chronic diseases to one in which, in Fries' model, of "morbidity compression", "in which the disease-free life span is extended through the prevention of disease complications and the symptom burden is compressed into a limited period preceding death." This dovetails well with what I have discussed above; people want to be healthy. They recognize that they are going to die, but they want to do this quickly, painlessly, and at the end of a long and healthy life. As a loved one of mine who is closer to this than many puts it, “someday I just won’t wake up”. Morbidity compression. If he is lucky, if we are all lucky, that will be how it happens.

But right now, our health care system is in fact designed to treat acute conditions and acute exacerbations of chronic disease, not to maintain the care and the health of people who have not yet developed chronic disease or are stable. More to the point, our system does this because this is what is paid for; we are just scratching the surface of the ideas of “chronic disease management”. In fact, we pay so well for acute interventions that hospitals are hiring acute “interventionalists” at extraordinary salaries compared to their colleagues in the same specialties that actually manage people over time. For example, “stroke neurologists”, or sometimes interventional neuroradiologists, who can inject clot-busters into the arteries of people with acute strokes make perhaps 2-3 times what a neurologist who just manages chronic neurologic diseases does (not that much more than regular radiologists, who are overall much higher paid); this is because the hospitals that employ them are so highly reimbursed for these procedures.

The need to manage actual people, especially when they have chronic disease, not just an acute episode, is obvious to most of us. It may even be obvious to the insurance companies and other payers, to the hospitals who support the acute interventionalists, but so far they haven’t changed what it is that they pay for, what it is that is financially incented. I write a lot about primary care, but it is not only primary care. Commenting on my last piece, Social determinants key to the future of Primary Care, a neurologist colleague who cares for people with Amyotrophic Lateral Sclerosis (ALS), Lou Gehrig’s Disease, a terrible and always fatal degenerative condition that satisfies almost none of the criteria for “morbidity compression”, wrote:

But the group health care model is also the best for chronic rare diseases managed by subspecialists....this is what we do in ALS clinic on Monday mornings. You should come visit, Josh, at 8 when all the folks (speech therapy, physical therapy, occupational therapy, social workers, dieticians, equipment providers, respiratory therapy) meet with the neuromuscular neurologists to discuss each case. Then we see them and all weigh in and we give patient a printout with advice from each. But, alas, there is no way to pay for this without support from local and national foundations....Medicare doesn't cover it by far.

I wrote back:

Of course. In this sense, you are sharing the same issues as primary care doctors -- you are managing patients, not just a single episode of disease. Certainly ALS is a disease, but it is a chronic one that takes over people's -- and their family's -- lives, and requires not only complex and interdisciplinary, but long-term, management. Indeed, the concept of the medical home was developed in the 1960s by the specialty pediatricians managing kids with chronic diseases such as cystic fibrosis, juvenile diabetes, and sickle cell, which share with ALS the fact that there is one disease that dominates the lives of the patient and their family; to care for it requires managing not just the disease but working with the whole person and their family. It can also (but is not always in practice) be true of HIV clinics.

This is less true of many other adult diseases, which often co-exist --diabetes, hypertension, congestive heart failure, chronic lung disease, depression, arthritis -- so that one specialist is not interested in (or perhaps capable of) managing them all -- thus primary care for adults, geriatricians, etc.

It is virtually not at all true of those who do radiology, anesthesiology, single-time consults, or one-shot surgery, or one-shot-into-the-cerebral artery neuro-interventionalists. Or, to be short, any of the folks making a lot of money for single things, while the stuff that you do in ALS clinic is not paid for.

This is insane. We do not have a health system, and we do not even have a health care system. We have a medical care system, with the emphasis on the medical. It is fine to pay for an episode of care, but it is much more important to reward care.

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[1] Asch DA, Volpp KG, “What Business Are We In? The Emergence of Health as the Business of Health Care”, NEJM 367(10);887-89. DOI: 10.1056/NEJMp1206862

[2] Marvasti FF, Stafford RS, “From Sick Care to health care -- re-engineering prevention into the US health system", NEJM, 367(10);889-91. DOI: 10.1056/NEJMp1206230

[3] Freeman J, “Towards a definition of holism”, Br J Gen Pract. 2005 Feb;55(511):154-5. PMC1463203

Not Getting What We Pay For

The Washington Post on Sunday, November 30, covered the issue of the amount of money that the US spends on health care – far more than any other country, nearly twice per capita of #2 – and the poor health outcomes that we get from it. The article notes that:
“The United States today devotes 16 percent of its gross domestic product to medical care, more per capita than any other nation in the world. Yet numerous measures indicate the country lags in overall health: It ranks 29th in infant mortality, 48th in life expectancy and 19th out of 19 industrialized nations in preventable deaths.”

This is not news – health policy experts, scholars such as those from the Dartmouth Atlas project among many others, organizations such as Physicians for a National Health Program, labor unions, churches, and consumer groups have been citing these statistics for many years. In addition to the more horrifying statistic – that 49 million Americans are uninsured, and probably another 30 million have significantly inadequate insurance. These data have been around for a long time, and are getting worse. The Commonwealth Foundation, in its 2008 report issued in July, found that the US health system scored only 65 out of a possible 100 on measures including healthy lives, quality, access, efficiency, and equity, and that we have not improved since their last report, in 2006. In the area of “mortality amenable to medical care” the US ranked 19th out of 19 countries examined, down from 15th in 2006. (We had improved some, but other countries improved more. And we do this while spending twice what other industrialized countries do.) http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682nd.org/publications/publications_show.htm?doc_id=692682

What is perhaps news is that the Washington Post and other mainstream media outlets are beginning to cover it seriously. Beginning to have found enough friends and relatives in their own neighborhoods and workplaces who are suffering to realize that it is not just a problem for “them”. Beginning to recognize that the Cassandras on the “fringe” have in fact been exactly correct; we spend too much, we cover too few people and we have poor health outcomes. We do not, in fact, have the best health system in the world. Very far from it.

We may provide the best health care for certain problems that require expensive technology (and “require” is different from “commonly used”, as the article point out.)
But only to those with coverage. Good coverage. Not everyone. And those same people with very good coverage may be getting BAD care because of the perverse incentive that doctors, hospitals, and other health providers are paid for doing more, not keeping you healthy.

The Post article continues with a quote from Peter Orszag, head of the Congressional Budget Office, who was nominated last week to be director of the Office of Management and Budget in the Obama administration. “Even if only a third of that could be invested in critical programs, imagine the possibilities. Given the scale of it, I am puzzled as to why we are not doing more to improve the efficiency of the health system."

Note that “efficiency” is the lowest score that the US received in the 2008 Commonwealth Fund report. Efficiency scores were low because of poor performance on measures of avoidable hospitalizations; inappropriate, wasteful or fragmented care; variation in quality and costs; administrative costs; and information systems. Arguably, these are the areas which are most responsive to a strong primary care infrastructure (see a future blog entry).

As can be seen by the attached chart, however, it is clear that the problem isn’t that we don’t have enough administrators. Perhaps the answer is more along the lines of “corporate – especially insurance company – profit”.