The Primary Care Crisis and Health Care Reform

Primary care crisis is a phrase we have heard many times. Often, it reflects not just a societal circumstance but the reality for health care professionals working first-hand with the medically underserved or vulnerable populations. These professionals are considered safety net providers because they deliver health care to uninsured patients, underinsured patients, and Medicaid patients. Safety net providers work in community health centers, federally qualified health centers, public hospitals, school-based clinics, teaching and community hospitals, and local public health clinics.¹ Without safety net providers and their supporting institutions, many communities would have little or no contact with the health care system.

Health care reform must ensure that our workforce is able to meet the demands of delivering primary care to patients. Program funding, financing mechanisms and incentives, and implementing infrastructure changes are all needed to ensure that clinicians are attracted to primary care, faculty are in place to educate health care professionals, and health care delivery is efficient and effective. Ameliorating the problems presently impeding primary care delivery involves more than just training additional doctors to become primary care physicians. At the core of the debate are several issues: (1) how to address the financial reimbursement inequities seen in primary care and specialty care; (2) how health care will be delivered; (3) which professionals will provide primary care, oral health care, and behavioral health care; and (4) how emerging technologies will be used. If these issues are not addressed, health reform agreed upon by politicians may not be adequate for the patients, the health care workforce, or health care institutions.

Primary Care Workforce

Primary care practitioners include physicians certified in family practice, internal medicine, and pediatrics; nurse practitioners certified in family, adult, pediatrics, gerontology, and women’s health; physician assistants certified in primary care; dentists; mental health providers; and public health clinicians and professionals. We do not have enough health care professionals to bring comprehensive primary care services to medically underserved communities.

Developing a primary care workforce has been suggested as a solution to strengthen our safety net infrastructures, improve access and quality of health care, and reduce health care costs. An adequate primary care workforce would also ensure an emphasis on prevention and well-being, population health, and community health.

Physician workforce

There are approximately 817,500 physicians in the U.S. Of that number, primary care practitioners constitute one-third and non-primary care practitioners the remainder.² Other statistics underscore the concern this raises:

• • In 2008 only 17% of medical students chose primary care as a career path. The breakdown was 5% going into internal medicine, 6% family medicine, and 6% pediatrics.³

• • A 2008 study predicted that by 2025 there would be a shortage of 35,000–44,000 adult primary care physicians. Universal access would increase the present day shortage by 25%.⁴

• • A 2009 National Association of Community Health Centers report showed that 60 million Americans lack adequate access to primary care because of physician shortages.⁵

• • Each $10,000 increase in medical school debt decreases the chance of a student entering a primary care field by 1%. Average private medical school debt is $180,000.⁵

• • Even if there were sufficient primary care physicians to meet the need, minority physicians would still be underrepresented. Potential large indebtedness may deter students from low-income families from going into primary care.³

• • An increase of one primary care physician per 10,000 population in one state increased the quality rank by more than 10 places and decreased Medicare spending by $684 per recipient.⁴

• • The U.S. Health Resources and Services Administration (HRSA) reports that there are currently 6,080 Primary Care Health Professional Shortage Areas (HPSAs) with 65 million people living in them. In order to meet the demands, an estimated 16,585 professionals are needed.⁶

• • HRSA notes that there are 4,091 Dental HPSAs with 49 million people living in them. Approximately 9,569 dentists are needed.⁶

• • HRSA records 3,132 mental health HPSAs with 80 million people living in them and would...