Assume we successfully get health insurance for 32 million more Americans. Not a single person "falls through the cracks." Every aspect of Obamacare launches and integrates perfectly. The exchange websites are beautiful and intuitive; every state with gaps conjures an elegant fix. There's a quantifiable change in barometric pressure as the nation collectively sighs.
What does it mean to be able to afford care if no one is there to provide it?
The moment would be fleeting. Panic resumes when the newly insured try to get appointments to see doctors. Overbooked, miles away, or otherwise inaccessible; what does it mean to be able to afford care if no one is there to provide it? Within the decade, the U.S. physician shortage will be around 91,500, with about half of them in primary care. Already today, 60 million Americans live in federally designated primary care shortage areas.
That's the picture painted by demographer and senior research fellow with the New America Foundation Phillip Longman in the current issue of Washington Monthly, where he takes a thoughtful at look at how federal dollars spent training physicians are distributed.
Residency training programs, which are the on-the-job work done after graduating from medical school but before doctors fly solo, are paid for by federal taxes. It costs the government around $100,000 per year to train one doctor. (The resident gets about $50,000 in salary, and the hospital gets the other half.) The 759 institutions in the U.S. with residencies get a total of around $13 billion federal dollars every year.
But many hospitals aren't using that money to do what the taxpayers most need. 158 of them produce zero graduates that go into primary care. The worst offenders, in terms of the number of primary-care physicians produced, are the hospitals we hold in highest regard. Those perennially among the "top hospitals" in nebulous magazine rankings: Mass General, New York Presbyterian, Cleveland Clinic, Brigham and Women's, Stanford, Washington University in Saint Louis, etc.
Training at these places comes with prestige, credibility, esteem. It's valued among patients searching the Internet to find a new doctor, and has cachet within the physician job market. Yet data from the Graham Center at George Washington University puts all of those among the 10 worst institutions in terms of producing the doctors that the U.S. most needs.
Longman describes the scene at Johns Hopkins:
... Its teaching hospital in Baltimore towers over a low-income neighborhood designated by the federal government to be suffering from a shortage of primary care doctors. Yet between 2006 and 2008, of the 1,148 residents who graduated from Hopkins's residency programs, only 8.97 percent went into primary care. Only two graduates went on to practice in a federally qualified public health clinic, and not one participated the National Health Service Corps, a program designed to encourage doctors to practice in underserved areas. In 2009, Hopkins residency programs costs the taxpayers $80.7 million.
The problem is not new; even in the 1960s there was talk of overspecialization as a burgeoning problem. Longman traces the roots back earlier, when after World War II General Omar Bradley started using the Veterans Administration hospitals to train new doctors, and got federal money for doing so. Then in 1965, the passage of Medicare guaranteed subsidies to private institutions, as well, for medical training.
Longman also profiles the now-prototypical overworked, underpaid primary care physician:
Linda Thomas-Hemak grew up in a small town outside of Scranton. Inspired by the example of her family's physician (an old-fashioned doctor named Thomas Fadden Clauss who still made house calls in the snow), she made her way through medical school and then on to Harvard's combined medicine and pediatrics residency program at Massachusetts General Hospital. She was on her way to becoming chief resident at Mass General, she says, when she was drawn back to her roots, returning to Scranton in 2000 to join her aging mentor in his local practice.
She soon discovered, however, that being a modern-day primary care doctor, especially in a medically underserved area like Scranton, left her with little time to breathe. In short order she found herself responsible for 2,600 patients. "I felt I could never get a cold or take a sick day," she says. "I felt so far away from Harvard." She felt frustrated, too, that so many of Scranton's aspiring young doctors would become discouraged by the lessons they took from seeing how she and her colleagues were struggling. "At the end of the day you take bright, idealistic, and Pollyannaish students and expose them to that, what do you think will happen?"
Thomas-Hemak's experience led to the founding of The Wright Center which, like some VA primary care clinics, is becoming a model of integrated team-player primary care training. ("The mission of the Wright Center is to provide excellent graduate medical education in an innovative and collaborative spirit in order to deliver high-quality, evidence-based and patient-centered care to the communities we serve.")