T.R. Reid

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.

In these first decades of the 21st century, the United States is the richest, strongest, most innovative nation on the planet. Americans like to chant “We’re Number 1”—and by many measures, they’re right. But in one crucial area of human endeavor—keeping people healthy—the mighty United States is a third-rate power.

All the other industrialized democracies have significantly better health outcomes than the United States—longer life expectancy, better recovery rates from illness or injury, less infant mortality.¹ Yet these nations spend, on average, half as much as the United States does for health care.¹ And these other rich democracies guarantee health care for everyone—while the United States leaves 29 million people ages <65 years with no health insurance, and another 50 million with deductibles so high that they are effectively uninsured.^2,3

This disgraceful state of affairs is not the fault of the nation’s physicians. Rather, the problems with health care in the United States stem from the system that American providers have to work in.

Health care has become big business. As the physician-turned-reporter Dr. Elisabeth Rosenthal notes in An American Sickness: How Healthcare Became Big Business, profits have come to matter more than patients for much of the $3.3 trillion US health care industry.^4,5 And the financial winners in our system—notably the “Big Four” health insurance giants, the for-profit hospital chains, and “Big Pharma”—fight hard to protect their profits. When the Affordable Care Act (“ObamaCare”) was first proposed, one of its main goals was to cut the administrative costs of health insurance, to force the private insurers to run their business as efficiently as Medicare. The insurance industry didn’t like that; its lobbyists fought back, successfully. As passed, the law allows the insurers to add up to 20% in administrative fees to every doctor and hospital bill—which adds hundreds of billions of dollars to the nation’s total health care spending every year.

Primary care doctors earn significantly less than specialists. But it doesn’t have to be that way.

Then there’s the problem that health-care economists call “specialty distribution imbalance.” In plain English, this means that the United States has too many doctors working in narrow (but highly compensated) subspecialties and not enough in the primary care fields of family medicine, internal medicine, and pediatrics. This is one more area where our country is out of sync with other industrialized democracies.

When I traveled the world studying health care systems, economists and government health ministers regularly told me that an efficient system should have 2 primary care providers for every 1 specialist. That is, primary care should make up about 66% of the overall physician work force.

If a 2:1 ratio of primary care providers to specialists is right, then the United States is upside down.

Most rich countries come close to this desired ratio. In the United Kingdom, family doctors working out of their own offices (it’s called a “surgery”) and treating patients on the local High Street (that is, Main Street), control 70% of the National Health Service (NHS) budget.⁶ “That’s the framework of the NHS, and of course we want to keep it,” John Reid, the UK’s former Minister of Health, told me. “If you just pop into your doctor’s surgery on the high street, that’s often just as effective, but never as expensive, as waiting to see a specialist.”

Continue to: If that 2:1 ratio is the right proportion...

If that 2:1 ratio is the right proportion for an effective health care system, the United States is upside down. For decades now, some two-thirds of new medical graduates have gone into narrower specialties, leaving our country with a serious shortage of primary care physicians.⁷ This situation helps to explain the higher cost and poorer overall outcomes that characterize American health care.

“Health care is often delivered according to a model that concentrates on diseases, high technology, and specialist care,” a report from the World Health Organization noted.⁸ “The results are...higher overall costs, and exclusion of people who cannot pay.” The report concluded that an emphasis on primary care leads to better outcomes for the same level of investment. This simple truth has been called the “Iron Law” of health care systems.

How can the United States get more primary care physicians? One answer is compensation. American primary care doctors routinely earn significantly less than specialists. But it doesn’t have to be that way. When I asked my family doctor in London, Dr. Ahmed Badat, why it is that 62% of British physicians are in family care, he was blunt: “Under the NHS, I make twice as much as a cardiac surgeon.”

If the big payers—government programs and private insurers—beef up fees for primary care (and pay for it by reducing compensation for specialists), more young American med students are likely to choose that route. Repayment plans that forgive the student loans of those in primary care fields also would attract more newly-minted physicians; these programs already are in place in several states.⁹

Continue to: Medical schools also have a role...

Medical schools also have a role to play. It’s no secret that the schools have emphasized specialties, with faculty members often steering their best students into narrow fields. But schools could promote an atmosphere in which primary care is treated as the most desirable destination for new doctors. Actively seeking out, and accepting, applicants who say they want to practice primary care is another key tool the medical schools could employ to deal with this national problem.

More doctors in primary care would mean better health care at lower cost for American patients. It’s long past time to take the steps needed to reach that goal.