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!

The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That the US health system is (to quote the opening of an important book*) “broken”, is obvious to almost everyone. It’s a mess. Even calling a “system” is probably incorrect. It costs a tremendous amount of money, generally 2-4x per capita what any other wealthy country spends, and generates far worse public health outcomes (even before the wackadoodle RFKJr became Secretary of HHS) such as longevity, disability-adjusted-life-expectancy (DALE), infant mortality, cancer survival, and almost all other measures. It also is very difficult to access, just getting to see a doctor, as well as financially. This situation has long been true for the poor and much of the working class. It is getting worse as low-income people lose access to Medicaid because of cuts to ACA subsidies or because they live in a state that never expanded Medicaid, and for rural people who are both, on average, older (and thus more likely to have health problems) and poorer. Over time it has increasingly become something that affects working class people, as insurance companies raise their rates, employers become stingier with paying premiums, and, very importantly, as the power of unions has been dramatically eroded by a society concerned only with corporations making the most possible money. It is critical to remember that the health insurance benefits employed workers gained resulted from the struggles of unions, never from the generosity of corporations.

The days of “Cadillac health plans” for unionized workers are long gone, and they are finding themselves in the same pool of too many people seeking too unavailable health care at too unaffordable costs. The new Trump administration plan for the ACA will make things much worse; it may offer lower-cost plans in terms of premiums but with enormous deductibles (‘New A.C.A. Plans Could Increase Family Deductibles to $31,000’, NY Times, Feb 26, 2026). So if you get sick and need care, you’re really screwed, and if you don’t you’re paying insurance premiums for nothing!

And now even those in privileged economic positions, who have money and sometimes even personal access because they are doctors, are finding themselves struggling to access care. People can’t find doctors, especially primary care doctors like family physicians and general internists who can manage their health and the input from various specialists. When they can find them, it is hard to get an appointment. It is very difficult to talk to them, or get a message to them, or speak to anyone who works for them who has any clinical knowledge or understanding. Some people say “I have a good doctor, they respond to my calls, or I can communicate on a health portal,” but these grow fewer. I know physicians who have real difficulties! They need supplies for their insulin pumps, but the insurance companies require notes from their doctors, and it is almost impossible to reach them. I know health care professionals who have heart problems requiring them to wear machines recording their heart rhythm over time, who must wait in lines stretching out the door to see their cardiologists. This is bad, not because they are better educated, wealthier, or health care professionals, but because it is bad for everyone. These people, at least, be able to afford to get a “concierge” doctor who they pay out of pocket, but clearly this is not a solution for most folks. 

We are in the grips of a perfect storm, with insurance companies raising their rates and finding reasons to deny care, a shortage of doctors in many areas, both geographic and by specialty, especially including primary care, with doctors having such speed-up of their work that they scarcely have time to see their patients not to mention respond to calls or notes. We have federal and state governments cutting back public benefits, including not only Medicaid but also Medicare and the VA. Doctors no longer work for themselves where they can make decisions about how to run their practice, and balance work and income, but for giant hospital “healthcare” systems and private equity investors interested only in profit.

Well, you know, maybe “perfect storm” is the wrong analogy. That phrase implies that the bad situation you find yourself in is the result of several unrelated events that come together coincidentally at the same time. This is not the case in the health care crisis. While a lot of things seem to be happening together, they are all manifestations of one single thing:

THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST.

That's it. That is 100% of the problem. A lot of effort is spent trying to transfer blame between blameworthy players, with insurance companies saying providers are too greedy, providers saying insurers don’t pay enough. And everyone blames the pharmaceutical industry and even components of that industry – drug manufacturers, giant retail pharmacies, and “PBMs”, the middlemen between drug companies and insurers – blaming each other. But this “it’s not me, it’s them” is all a load of crap. Yes, sometimes one part of the “healthcare” industry is doing better financially than another, sometimes one corporate behemoth puts another out of business, but what is never a major consideration – and I put forward it should be the only consideration – is what improves the health of the American people, as individuals and as a whole. You, the “patient”, the sick person who needs care, is the one player in this whole thing whose interests are not getting the consideration they deserve – which should be ALL of it.

The growing trend, which is the proof of all of this, is the “vertical integration” of the components of the system. This means that the same company is the insurance company, the provider, the drug supplier. It feeds itself sucking out your money at every turn while denying you the care that you need. Several recent posts on the “Health Care Un-covered” substack detail aspects of this, including ‘The Economic Exploitation of Independent Physicians by Insurers’, and recently ‘2025: Big Insurance’s $1.7 Trillion Year’ which shows that while they ARE making these outrageous amounts (from YOUR pocket, whether directly in premiums, co-pays, and deductibles or premiums paid by your employer in lieu of higher wages) the bosses THEY answer to, the sharks on Wall St., are harassing them to do more, charge more, deny more care, because it isn’t enough; they aren’t making enough  profit! They need more!

I said at the beginning of this piece that “almost everyone” realizes that our healthcare system is a mess, and I think this is true. Certainly, those profiting from it, all those insurance companies and health systems and private equity companies and drug companies, know it. They love it. They’re making out like bandits, one might be tempted to say, if only bandits could begin to compete with them in cupidity, heartlessness, and immorality.

The truly infuriating thing is that our governments are in the practice of enabling them, of enhancing their power, of increasing their profits (see, for example, the gargantuan efforts to move US seniors out of traditional Medicare, an efficient and cost-effective single-payer plan to Medicare Advantage, which puts them back at the mercy of insurance companies; see for example Medicare re-enrollment: Time to consider being dissatisfied with a new plan!, Oct 25, 2025). Most legislators and their health pundits who are not the out-and-out-on-the-take corporate enablers that characterize the Republican party are the somewhat-less-but-really-still-on-the-take corporate enablers of the Democratic party!

We regularly hear from even somewhat progressive (not to mention the right-wing) think tanks and academics and legislators that it would be impossible to change the system to truly benefit the health of the American people, and not the pockets of big corporations, even though it has been done in every other wealthy (and many less wealthy) countries in the world. The key change here is to take the profit (or most of the profit, or the possibility of generating ever more profit) out of the health system. The problem is simply NOT that people use “too much” health care and cost too much money; the problem IS simply that insurers and big health systems and Wall St. and drug companies MAKE too much money and are taking the money we pay for health care out of health care!

The only people who are going to speak for the health care needs and interests of the vast majority American people are those people themselves. Demand of your politicians that they commit to single-payer improved and expanded Medicare for All, demand that they pursue policies that actually get more primary care doctors out in practice by decreasing the payment prejudice for subspecialists and banning completely the corporate practice of medicine.

And if they don’t, vote them out!

 

*Joshua Freeman, Health, Medicine, and Justice: Designing a fair and equitable healthcare system, Copernicus, 2015.

More residency slots: Good, but not going to solve the primary care shortage...

The Center for Medicare and Medicaid Services, CMS, recently announced that it will be funding an additional 440 residency positions in 135 hospitals in 37 states. This is a good thing, and a step in the direction of reducing the glaring shortage of physicians in the US. CMS already funds most of the residency positions, something which is probably not intuitively obvious to those not involved in post-graduate medical education, but it is so even if it is not clear why (as opposed to, say, Congress directly appropriating such funding). This is important because while you are a doctor (physician) on graduation from medical school, you can’t obtain a license to practice anywhere without residency training (e.g., family medicine, pediatrics, surgery, psychiatry, radiology, etc.). Thus, past efforts to increase the number of physicians by increasing the number of medical schools (or the class size in existing medical schools) fail, because the residency pipeline has been static. It has only, perhaps, decreased the number of international medical graduates filling those positions. 

CMS further states, per this piece in MedPage Today, that 2/3 of those slots will be in primary care and psychiatry, two areas in which the shortage of physicians and other clinicians is particularly acute. This is also good, but will continue to have limited impact, at least until we see exactly which specialties are getting those positions. “Primary care” is not a specialty in which there is a residency; usually the term is used to include family physicians, general pediatricians, and general internists (as well as those general practitioners who completed only one year of post-graduate training, ie., internship, when that was sufficient to receive a license). The problem is mostly with internal medicine. After completion of a 3-year internal medicine residency, the large majority (about 80%) of graduates go on to complete a fellowship in an internal medicine subspecialty (cardiology, nephrology, pulmonary medicine, endocrinology, etc.). They do not practice primary care. In addition, about half the remainder become hospitalists, caring for people in the hospital only, leaving only a small number of internal medicine residency graduates to practice primary care. While many pediatrics graduates also sub-specialize or become hospitalists, the percents are much lower. On the other hand, about 90% of family medicine graduates practice outpatient primary care. In addition, it likely includes OB/Gyn which is not primary care.*

It would be good if we could get an accurate accounting. There are “general medicine” or “primary care medicine” residency programs among the internal medicine programs which produce higher percentages of primary care outpatient practitioners -- but still not all, or even close to the 90% of family medicine. We need to know if the new CMS positions that are designated “primary care” include internal medicine; if they do, obviously the output, the number of new outpatient primary care doctors, will be significantly lower. Why should they be unclear about this? It is in the interests of many institutions to keep it fuzzy. Medical schools have long reported on the percent of their graduates entering primary care, and they have included all those entering internal medicine (and sometimes OB/Gyn or even Emergency Medicine) as well as pediatrics and family medicine, inflating the percent that is ostensibly primary care. This practice has been called “the Deans’ lie”. The Association of American Medical Colleges (AAMC), quoted in the MedPage Today piece, has a similar reason to obfuscate the truth; their members are those same medical schools (and the teaching hospitals associated with them) and their leaders, both in AAMC and in the individual schools, are overwhelmingly non-primary-care subspecialists.

One of the main reasons for the shortage of primary care physicians, and thus this purposely-inaccurate effort to paper over the dearth of them, is that, while physicians overall make much more than the average person, there is a great disparity in income between the specialties, often being 4-5 times as much for certain specialists as others. The shortage of primary care physicians and psychiatrists that this change is making a small effort to rectify is very likely because pediatricians, family physicians and psychiatrists are on the low end of the physician income scale. The table below, from “PhysiciansThrive.com”, is one example, although it may actually understate the income of the top specialties.

 

 

The lowest-paid physicians are doing well compared to most Americans, but they often come out of school with $250K + debt, which is, of course, owed with compound interest. The income gap between specialties has to be narrowed, and some studies suggest that if primary care physicians made 70% of what other specialists do, money would largely cease to be an issue in student specialty choice. But how could we do that? Isn’t it really complicated?

Well, not as much as you might think. A recent installment of the New York Times feature “The Ethicist” responds to the question from a reader “Should I Feel Bad About Joining a Concierge Medical Practice?”. This in itself is a complex, but separate, question. However, the Ethicist notes in their response that one of the reasons it is hard to find a primary care physician is that 

‘Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations.’

I was surprised to see this addressed in this column; while it is absolutely true, it is rarely discussed. The comment makes 3 points which together drive the income disparity:

1.     CMS sets reimbursement rates for Medicare, but it essentially drives all reimbursement as insurance companies use Medicare rates (or multiples of them) to determine their own payments.

2.   These Medicare rates are set by “relative value units”, or RVUs, so that some sort of equivalence can be made. For example, how many comprehensive examinations by a primary care doctor or assessments by a psychiatrist or chest x-ray interpretations by a radiologist is worth one gall bladder removal by a surgeon or joint replacement by an orthopedist? This is essentially dividing up a pie of set size; when one “gains” another “loses”.

3.  While CMS sets these RVU ratios, they usually rely upon the recommendations of a little-known group called the “RUC”, appointed by the AMA. As the Ethicist notes, this committee is overwhelmingly specialists. And, so, not surprisingly, the distribution of the pieces of the pie tend to favor those specialists, and, indeed, procedures are valued more than conversations. And “conversations” kind of minimizes the communication between people (patients) and their primary care doctors, as people’s stories greatly inform both the diagnosis and the best treatment (and the one the patient is going to accept and follow through on), and are essential for the patients to know what is going on. And presumably interactions with psychiatrists are more than simple “conversations”. (I have written about the RUC several times, including Doctors' incomes and patient coverage: both need to be more equal, Jan 26, 2014 and Pay primary care more: Kennedy may be getting this one right!, July 23, 2025.) 

So there is a clear-cut way to fix these disparities: CMS simply needs to adjust the RVU basis, increasing the value of “conversations” and really thinking and assessment and decision making relative to procedures. Of course, this means the highest-paid subpspecialists would make less than they do now, and so they are going to fight it, as are their organizations and groups like the AAMC. But really, even if they take a significant cut, they are a long way from the Food Bank!

The question is: Will CMS do this? Pressure from you, the people who can’t get into a doctor, is definitely going to help!

 

*Primary care is comprehensive care of the needs of the patient, with referral to specialists when needed; internists and geriatricians and pediatricians limit the ages of their patients but they provide comprehensive care for them. While some women only see an OB/Gyn, they only provide care for a woman’s reproductive tract, not comprehensive care.