PAYMENT: When the Uninsured Become Insured, Who Will Care For Them?

Dr. Benjamin Brewer, in his Wall Street Journal column (subscription, or read a summary in the Wall Street Journal health blog) wonders: who will take care of the 47 million uninsured in a system that already undervalues family medicine and primary care?

We would suggest that the uninsured are getting care – not enough care, too- late care, expensive emergency room care instead of more appropriate and cost-effective primary care. But Dr. Brewer’s central point is correct. Our system gives short shrift to primary care and is chockfull of incentives for fragmented specialization. In the health care system we envision for the future, primary care doctors (internists, family doctors, pediatricians, geriatricians, perhaps for some women OB/GYNs) would play an elevated role in coordinating patient care. And they would be paid for doing it well.

In the short run, though, there’s no doubt that Brewer is right in pointing out that the system undervalues primary care, both in money and status compared with specialists. The demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians, according to the American Academy of Family Physician's 2006 Physician Workforce Report. That's a 40% increase over the 100,000 family doctors at work in 2006, as Dr. Brewer notes.

But students aren’t flocking to primary care, which can have worse hours, less status and lower incomes than specialties. “Low payments to primary care doctors are discouraging those of us in practice and are dissuading new doctors from entering the field,” Brewer writes. For instance, only 65 more U.S. medical students chose family medicine for their residency this year than last year for a total of 1,172. (See a chart on the primary care trends here.) Compared with the bleak decline of the last 10 years, a two percent increase in family practice residents is cause for celebration among family doctors.

One last word -- we were disheartened that Dr. Brewer and several of the readers who commented on his column equate “universal insurance” with a single-payer government-run Medicare system. They aren’t synonyms. There are many ways to cover all Americans, and nearly all of the plans on the table in Washington these days use a mix of public sector and private market options. The presidential candidates are not advocating plunking an additional 47 million people in Medicare. Len Nichols, director of New America’s Health Policy Program, in a detailed post yesterday explained why simply expanding the 40-year old Medicare program is not the silver bullet for the complicated cost, quality and coverage challenges facing our system.