What’s missing in the US candidates’ healthcare proposals
Authors: Douglas Kamerow
Journal: BMJ (2008)

Although the Iraq war and more recently the sad state of the economy have dominated the political campaign for US president, healthcare problems have continued to be cited by voters as a big concern. Each candidate has a retinue of healthcare advisers, and their websites are full of position papers and multi-point plans on this topic.

Everyone agrees about the nature of the problem. Health care now consumes 16% of the US gross domestic product, and costs continue to climb. We spent about $7000 (£3518; €4719) per person on health care in 2006, over $2 trillion in all. Around 45 million Americans have no health insurance for at least part of the year. The population is ageing. We baby boomers, who expect and consume lots of health care, are now beginning to turn 65 and are going to be a big problem.

But despite all of the money we spend on high tech medicine, the US is consistently near the bottom of rankings of healthcare outcomes in developed countries. There are continuing concerns about the quality of health care and medical errors. While most patients like their doctors, they are grossly dissatisfied with the US healthcare system.

The candidates more or less agree on many changes that are needed to fix things: an increased focus on preventive medicine, wider use of computerised medical records to decrease errors and improve care, more information for patients, and improved care and coordination for people with chronic diseases.

The candidates differ, though, on the organising principles behind their prescriptions for change. The Republicans tend to focus on cutting costs and increasing patient choice and control over their health care, usually through some type of market-based solution where people can choose their own privately sponsored insurance. Democrats are for cutting costs too, but they give more attention in their plans to providing insurance coverage for everyone (or almost everyone) as a way to improve health and healthcare.

But unless I am missing something, all of the major candidates omit a major issue from their discussions and proposals. My search of the healthcare platforms of the candidates failed to find a single mention of the term “primary care.” Does no one realise that the current woeful state of primary care medicine in the US is both a likely cause of many of our problems as well a potential solution for them?

The advantages of a strong primary care infrastructure have been well documented in studies around the world. Where there is good primary care, patients have reduced mortality and better outcomes from cardiovascular and pulmonary diseases. They are hospitalised less frequently and use emergency services more appropriately. Strong primary care systems are associated with better delivery of preventive services and better detection of breast, cervical, and colorectal cancers. Patient satisfaction is better in primary care patients. Medical care delivered by primary care clinicians is less costly, with less testing and comparable outcomes. In areas of income inequality, increased primary care services are associated with reduced health disparities.

All of which argues that the US should have a vigorous primary care system. But in fact, primary care in the US is in crisis, and things are getting worse. Currently, primary care doctors, which in the US include general internists and general paediatricians as well as family physicians, comprise about 35% of the US medical workforce, compared to 50% or more in most industrialised countries. The number of US medical students choosing family medicine residencies decreased by half in the past ten years, as did the proportion of internal medicine residents who planned careers in primary care instead of a subspecialty. So not only are there too few American primary care doctors, but their numbers are likely to decrease in the foreseeable future.

This is not surprising, given that the median income of primary care doctors in the US is only slightly more than half of that of subspecialists. Graduating internists who go into primary care can expect to earn at most half of what their medical subspecialty colleagues make. Primary care doctors see more patients than subspecialists, and yet their income, adjusted for inflation, declined by 10% from 1995 to 2002.

What will it take to reverse these trends? What can the presidential candidates propose that would make a difference? Much of the needed reform is financial. Primary care doctors should be paid more. Care that is continuous and coordinated should be rewarded. Health-related counselling and other time-intensive but low-tech services should be reimbursed generously.

Funding subsidies could be used to increase medical student incentives to enter primary care training programmes. Similar incentives could be provided to medical schools and hospitals to partially offset trainee salaries. Loan forgiveness programmes for primary care doctors would make higher paying subspecialties less attractive and ease young doctors’ transition into primary care practice.

And, finally, the practice of primary care medicine should be improved by providing increased support for preventive care, better reimbursement for non-traditional service provision (such as group and email care), and more incentives for healthcare delivery by primary care teams.

Primary care medicine is a crucial missing piece of the healthcare puzzle. It needs to be a part of the proposals of all the presidential candidates.