We have had about a 75-year experiment with ESI, but its track record is one of continued decline over the last 30 years—fewer people covered, less coverage for more costs, and less value of that coverage. ESI was more an accident of history than a well-planned financing system for health care. Today, rapidly accelerating costs are the Achilles heel for ESI, both for employers and employees, as they are for the entire market-based ‘system’ itself.

ESI arose at a very different time than today. Beyond the labor shortage, American business was dominant with little concern about foreign competition, and labor unions were strong. Many workers could reasonably expect to hold their jobs for their working life.

But those days are long gone. Most workers these days have multiple jobs, even careers, over their working years. By 2002, only about one-half of employed men or women could claim to have held their job for ten years. (Tejada, C. A special news report about life on the job—and trends taking shape there. Wall Street Journal, September 25, 2002: B5) Loyalty between employers and employees has dropped way off in recent years, part-time workers are not eligible for benefits, and union membership hovers around 10 percent of the workforce.

These markers show a long decline of ESI, as well as the decreasing benefits to enrollees:

• In 1980, more than 70 percent of employees working more than 20 hours a week were covered; that number fell to 56 percent by 2005, with coverage already unraveling as employers shifted from defined-benefits to defined-contributions. (Mishel, L, Bernstein, J, Allegretto, S. The State of Working America 2004/2005. Ithaca. Cornell University Press, 2005)

• Over the 13-year period that Kaiser Family Foundation has been tracking premiums for ESI, employee contributions have increased by 168 percent as compared to increased wages of 50 percent and inflation of 38 percent. One-half of employees of companies with fewer than 200 workers now have a deductible of $1,000 or more for single coverage as compared to 16 percent five years ago. (Altman, D. Rising health costs are not just a federal budget problem. Kaiser Family Foundation, September 27, 2011)

• Premiums for family plan ESI coverage have gone up by 9 percent this year, triple the increase in 2010; family premiums now total $15,073 on average, of which $4,129 is paid by employees (consider that these costs may have little to do with what employees end up paying for their health care, especially those who are older or have one or more chronic diseases!). (Appleby, J. Costs of employer insurance plans surge in 2011. Kaiser Health News, September 27, 2011)

• In 2012, average annual employee premiums for health insurance are expected to go up by another 10.6 percent. (Japsen, B. Companies pass on more of health costs to workers. New York Times, October 3, 2011: B3)

• Many of the so-called ESI plans cannot really be called insurance, since they now pass along so much of the costs of care to enrollees even as the extent of coverage withers away. Retiree and disability coverage are being cut by many companies, and their employees are increasingly being herded into lower-cost networks of providers with quality of care in question. As Dr. Don McCanne, Senior Health Policy Fellow for Physicians for a National Health Program, sums up: “The new national standard in health insurance is unaffordable under-insurance”. (McCanne, D. Quote-of-the-Day, September 13, 2011)

Beyond the increasing unaffordability of ESI for employees, employers—big and small—have the same problem with no end in sight. General Motors says it spends about $5 billion on health care expenses each year, adding between $1,500 and $2,000 to the sticker price of every car out the door. That burden is many times higher than what neighboring competitors just across the border in Canada pay for health care, rendering GM much less competitive in global markets. (Johnson, T. Healthcare costs and U.S. competitiveness. Council on Foreign Relations, March 23, 2010) Small business (with fewer than 100 employees), accounting for about 40 percent of the private U.S. workforce, cannot keep up with the growing cost of ESI coverage. The small employer market has been one of the most profitable for private insurers, with premiums climbing by 74 percent between 2001 and 2008.

The so-called health care reform legislation, the Affordable Care Act of 2010, will not fix this problem. Having handed over a combined employer and individual mandate to the private insurance industry, with minimal regulatory clout, the bill (if and when it is implemented) lacks any semblance of cost containment measures. Federal waivers already give employers whatever they want, as illustrated by a recent HHS ruling that allows McDonald’s Corp. to keep its very low limits of annual coverage of just $2,000 a year. (Adamy, J, Johnson, A. Rules eased for some health plans. Wall Street Journal, November 23, 2010: B1) Whereas President Obama promised that the average American family would save $2,500 a year on health insurance premiums, the Congressional Budget Office later projected that their cost would only increase. (Hemingway, M. Obama promised $2,500 health care savings; CBO says plan is $2,300 price increase. Washington Examiner on line, March 10, 2010)

M. Obama promised $2,500 health care savings; CBO says plan is $2,300 price increase. Washington Examiner

Adding all of this up, we can only conclude that employer-sponsored health insurance, and the overly expensive, wasteful private insurance industry upon which it is based, is in its death throes. As the Vice chairman of Ford Motor Co. said in 2004: “Right now the country is on an unsustainable track and it won’t get any better until we begin—business, labor and government in partnership—to make a pact for reform. A lot of people think a single-payer system is better.” (Downey, K. A heftier dose to swallow. The Washington Post, March 6, 2004). Some 50 years ago, Walter Reuther, as the national president of United Auto Workers, saw the future this way:

“When American corporations reached the point where they couldn’t make their business more efficient without making it less profitable, when their dependency ratios soared to unimaginable heights, when they got tens of billions behind in
their health-care obligations, when the cost of carrying thousands of retirees forced them to stare bankruptcy in the face, they would come around to the idea that the markets work best when the burdens of benefits are broadly shared.” (Reuther, W. as cited by Gladwell, M. The risk pool: What’s behind Ireland’s economic miracle and GM’s financial crisis? The New Yorker, August 28, 2006, p 35)

We have to move beyond denial of this problem, and rein in markets that fail the public interest. We can no longer afford ESI or the private insurance industry. Unless we move past political gridlock on this big issue toward a new partnership between labor, business and government, they can bankrupt us all!

There is an answer, of course, in plain sight—not-for-profit, improved Medicare for All, funded by broadly shared progressive taxes that cost patients, families and business less than they are now paying while assuring universal coverage in a less bureaucratic and more accountable system.

John Geyman, M.D.
Professor emeritus of Family Medicine
University of Washington

Author of Do Not Resuscitate: Why the Health Insurance Industry is Dying and How We Must Replace It and Hijacked! The Road to Single-Payer in the Aftermath of Stolen Health Care Reform (Common Courage Press, 2008 and 2010)

To buy books from John Geyman visit: http://www.copernicus-healthcare.org

We now have to wonder what has happened to our sense of fair play, our self-proclaimed egalitarianism that has been part of our character for a long time. We need to ask whether we care anymore for our fellow citizens, and whether we can mount the collective political will to reverse course toward a kinder, gentler society?

Today’s mean-spirited political debate across the wide divide between the Tea Party and progressives stands in sharp contrast to previous times in the last century. Through the leadership of a strong and caring president, FDR brought us Social Security in the 1930s, the 1950s was a time of prosperity widely shared across our society, and the 1960s brought Medicare and Medicaid.

We are now seeing some interesting writing on this subject that helps us to understand how we got here and how we might get past these dark times.

In his classic recent article on the subject, Robert Kuttner, founder and co-editor of The American Prospect and co-founder of the Economic Policy Institute, draws a comparison with the failures of civic institutions of Germany in the late 1800s that prevented a national consensus with later global consequences. As he observes:

“One of our major parties has turned nihilist, giddily toying with default on the nation’s debt, reveling in the dark pleasures of a fiscal Walpurgisnacht. Government itself is the devil… Whether the target is the Environmental Protection Agency, the Dodd-Frank law or the Affordable Care Act, Republicans are out to destroy government’s ability to govern… The administration, trapped in the radical right’s surreal logic, plays by Tea Party rules rather than changing the game… The right’s reckless assault on our public institutions is not just an attack on government. It is a war on America.” (Kuttner, R. The war on America. The American Prospect 22 (8): 3, 2011)

In his new book Pinched: How the Great Recession Has Narrowed Our Futures and What We Can Do About It, Don Peck compares our times today with those in the First Gilded Age in this country in the late 1800s. The gulf between rich and poor was also very wide in those years. The Depression of 1893 led to a run on banks that crippled the financial system, extended families broke apart, communities became more transient, and the social fabric of society was shattered. (Peck, D. Pinched: How the Great Recession Has Narrowed Our Futures and What We Can Do About It. New York. Crown Publishers, 42-5, 2011)

Theodore Marmor, professor emeritus of public policy at Yale and Jerry Mashaw, professor of law, also at Yale, note how the language of our political leaders has changed from the 1930s to today—from “a morally resonant language of people, family and shared social concern to the cold technical idiom of budgetary accounting.” As they further observe:

“ In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other—not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements”, a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.” (Marmor, TR, Mashaw, JL. How do you say ‘economic security’? New York Times, September 23, 2011)

Henry Giroux, author of another new book, Education and the Crisis of Public Values: Challenging the Assault on Teachers, Students and Public Education, sheds further light on how all this has come about:

“As the left slid into organizing around mostly single-issue movements since the 1980s, the right moved in a different direction, mobilizing a range of educational forces and wider cultural apparatus as a way of addressing broader ideas that appealed to a wider public and issues that resonated with their everyday lives. Tax reform, the role of government, the crisis of education, family values and the economy, to name a few issues, were wrenched out of their progressive legacy and inserted into a context defined by the values of the free market, an unbridled notion of freedom and individualism and a growing hatred for the social contract.

…At issue here is the need for a new vocabulary, vision and politics that will unleash new, democratic movements, institutions and a formative culture capable of imagining life and society free of the dictates of endless military wars, boundless material waste, extreme inequality, disposable populations and unfounded human suffering.” (Giroux, HA. Corporate media and Larry Summers team up to gut public education: Beyond education for illiteracy, vulgarity and a culture of cruelty. Truthout, September 27, 2011) So we have some big questions here: who are we today, are we the country that we want to be, do we care about each other anymore, and do we have the collective will to assert ourselves against the bigoted interests of the few?

John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington School of Medicine, and author of Falling Through the Safety Net: Americans Without Health Insurance (Common Courage Press, 2005)

To buy a book from John Geyman, M.D., visit http://www.copernicus-healthcare.org

The public discourse is reaching new levels of ugliness, as illustrated by an audience at a GOP campaign event cheering the idea that that those without health insurance should just be left to die. (Krugman, P. Free to die. Op-Ed. New York Times, September 16, 2011: A23). GOP presidential hopefuls have no solutions to offer except the “freedom to choose” (your own fate!) and the private marketplace (which increasingly excludes those who cannot pay its rapidly increasing costs). In fact, they exacerbate the problem, under the guise of fiscal responsibility and austerity, by cutting government safety net programs while at the same time trying to exploit Medicare and Medicaid by further privatization.

These are some markers that show some of the impacts of this war:

• According to the U.S. Census Bureau, in 2010 49.9 million Americans were uninsured (which understates the problem since anyone with insurance for even a small part of the year was considered insured), the median household income was $49,445 (a drop of 2.3 percent from 2009), and 46.2 million people (including 22 percent of the nation’s children) were in poverty (the highest number in the 52 years for which estimates have been tracked). (U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States, 2010)

• In his recent editorial in The Progressive, Matthew Rothschild notes that, over the last 40 years, the top 0.1 percent of the population (152,000 people making more than $5.6 million a year) skyrocketed by 385 percent while the income of the bottom 90 percent (about 137 million people) dropped by 1 percent.(Washington Post) In the last ten years, the median income of working-age households has dropped by more than 10 percent (Economic Policy Institute). (Rothschild, M. Enlist for class warfare. The Progressive, September 20, 2011)

• According to a Gallup poll, 18.2 percent of Americans state they did not have money to buy food at all times in 2010. (Gallup, Washington, D.C.)

• The median household wealth of white families has fallen by 16 percent since 2005; Hispanic families dropped by 66 percent. (Pew Research Center Social & Demographic Trends project. Washington, D.C.)

• Three-quarters of the increase in U.S. corporate profit margins over the last ten years have come from depressed wages. (J. P. Morgan, New York City) (Harper’s Index 323 (1937): 15, 68, October, 20ll).

• U.S. corporations pay only 10.5 percent of their profits in taxes today (vs. 40 percent in 1961, with some paying no taxes. (Institute for Policy Studies, Washington, D.C.)

• Based on a definition of the middle class of those between the 30th and 70th percentiles of the income distribution, one-third of Americans dropped out of the middle class over the last 30 years. (Acs, G. Downward Mobility from the Middle Class: Waking Up from the American Dream. Economic Mobility Project. Pew Charitable Trusts, September, 2011).

• The average annual premium for health insurance for a family of four reached $15,073 in 2011, 9 percent higher than 2010 (Abelson, R, Bernstein, N. Health insurers push premiums sharply higher. New York Times, September 28, 2011: A1) (an unaffordable level about 30 percent of the median family income, or twice the proportion of income that seniors paid for health care when Medicare was enacted in 1965!).

• In the most recent study of mortality amenable to health care in 16 high-income nations, the U.S. ‘led’ the field with the most preventable deaths, and with the least improvement over a ten-year period; the authors concluded this poor
showing is likely due to “the lack of universal coverage and the high costs of care.” (Nolte, E, McKee, M. Variations in amenable mortality—Trends in 16 high-income nations. The Commonwealth Fund, September 23, 2011)

• The consumer confidence level is now only 45 percent. (Vital signs. Wall Street Journal, September 28, 2011: A1) Despite all this pain and suffering, the political process continues to ignore this national catastrophe in the name of austerity as the debate continues over the budget deficit, targeting federal spending for education, health care and other important public programs (but avoiding bigger issues, such as major defense cutbacks, real financial reform, campaign finance reform, and tax increases for the wealthy). The extreme right-wing of the Republican Party, activated and hobbled by the Tea Party, continues to hold Congress and the Obama Administration hostage as it pursues its nihilistic agenda, focused on winning further power in 2012 despite its lack of a plan to address these kinds of problems.

The present situation in health care boils down to a human and moral crisis that seems beyond the reach or concern of our current political leaders, conflicted as they are by enormous amounts of corporate cash that perpetuates our present, increasingly cruel market-based system. In our next post, we will explore whether we still can draw on a long-standing self-image that we as Americans care about each other.

John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington School of Medicine and author of Hijacked! The Road to Single Payer in the Aftermath of Stolen Health Care Reform (Common Courage Press, 2010)

To purchase a book by John Geyman, visit copernicus-healthcare.org

But as I discussed in a lengthy article four years ago, this theory has been fully discredited over the years as a cost-containment tool in U.S. health care. (1) (Geyman, JP. Moral hazard and consumer-driven health care: A fundamentally flawed concept. Intl J Health Services 37 (2): 333-51, 2007) Instead of cutting health care spending, cost-sharing leads many patients to delay or forego necessary health care, resulting in later diagnosis of illness and higher costs down the road, together with decreased quality and outcomes of care.

Overall health care costs are not reduced. Cost-sharing just shifts more costs to patients and families at a time when these costs are already unbearable for many. Meanwhile, the real drivers of health care costs continue unimpeded— perverse incentives within the medical marketplace that encourage physicians, other providers, hospitals and other facilities to deliver more services, whether appropriate or necessary or not; lack of price controls; blatant profiteering by Big PhRMA, investor-owned hospitals and medical supply companies; introduction of new technologies with lax requirements to document their effectiveness; and excess bureaucracy of our 1,300 private insurers.

Although it is now clear that cost-sharing will not fix our cost problems, and will just make patients sicker and increase the numbers of preventable hospitalizations and deaths, the policy-making community continues to bark up this tree. In fact, all the present trends indicate that increased cost-sharing, promoted especially by the GOP and many willing Democrats, will be imposed across the board in both private and public programs.

These examples illustrate the extent of this continuing trend:
• High-deductible plans with increased co-payments for visits and drug prescriptions and greater restrictions on network providers.
• Efforts to increase cost-sharing in private Medicare plans, including Medigap and Medicare Advantage programs.
• The Obama Administration’s “surrender in advance” proposal to introduce new co-payments for home health services for new Medicare beneficiaries (4) (Office of Management and Budget. Living Within Our Means and Investing in the Future. The President’s Plan for Economic Growth and Deficit Reduction. September 2011).
• Draconian Medicaid cutting services and increasing cost-sharing (e.g. Arizonans below the federal poverty level must make co-payments to gain access to care, causing many to forego care, a practice recently rejected by a the 9th U.S. Circuit Court of Appeals. (5) (Reinhart, MK. Copays break law. The Arizona Republic, August 25, 2011) But conservatives and many Democrats conveniently ignore these inconvenient facts about cost-sharing as a failed mechanism to cut health care costs:
• Despite the widespread and increasing use of cost-sharing over many years, health care inflation remains completely out of control.
• Physicians push the buttons for health care services much more than patients.
• The enormous costs of the multi-payer financing system are wasteful and unsustainable, and could readily be controlled by shifting to a single-payer financing system. The hypocrisy of the right on this issue boggles the mind. Consider these contradictory policies and assertions on the right:
• Blind ideological support of “market competition” as the answer to our cost problems when that is the main part of the cost problem, since real competition does not exist in health care markets (e.g. more consolidation all the time, wide latitude to set prices, little transparency, etc).
• Intent to dismantle Medicare and convert it into a voucher-based welfare program while at the same time opposing cost controls of private Medicare programs and negotiated drug prices that are so effective in the VA.
• Forcing increasing cuts of an already underfunded Medicaid program while promoting for-profit privatized Medicaid programs that offer worse medical care (6) (McCue, MJ, Bailit, MH. Assessing the financial health of managed Medicaid managed care plans and the quality of patient care they provide. The Commonwealth Fund, June 15, 2011) and further gouge the most vulnerable among us.
• Opposition to reforms of Wall Street abuses, where moral hazard of high-risk and exploitive investment practices continue unchecked. (7) (Browning, ES. Fed faces old foe as hazard returns. Wall Street Journal, August 29,2011: C1)
• Failure to even consider a single-payer, not-for-profit Medicare for all program that would assure universal coverage for our whole population with increased choice, more efficiency, fewer disparities and improved quality of care, all at less cost than employers, patients and families are now paying.
• Calling for a more limited role of government until big banks and other privateinstitutions face bankruptcy, then begging for bailouts and minimal follow-up regulation.
• Calling the Obama Administration’s recent proposal for minimal tax rules for those making more than $1 million a year “class warfare” as if the GOP hasn’t been waging such a war for many years. (8) (Knowlton, B. Republican lawmakers equate Obama tax plan with ‘class warfare’. New York Times, September 19, 2011: A 19)

Adding up all these examples of GOP duplicity and hypocrisy (to which many Democrats unfortunately yield), we have to ask when logic, common sense, evidence and fairness will take center stage for health policy makers and legislators? The way things are going could well be called legislative malpractice.

Space here does not permit fleshing out the necessary steps to real system reform that would also facilitate the rebuilding of primary care. Briefly, however, most if not all of these approaches will inevitably be required. In their approximate order of priority, they are:

1. Adopt universal health care coverage through single-payer national health
insurance (NHI). This is the only way we will ever get universal coverage so essential for optimal care of individuals as well as our population. It will help to enable the other elements of needed reforms by forcing new approaches to financing care. Exploitive profiteering can be eliminated while simplification of administration can bring greater efficiencies.

2.Rethink the goals of medicine and the paradigm of health care. We have developed a health care system that overemphasizes the reductionist biomedical model, gives short shrift to behavioral and social aspects of illness, and all too often, continues high technology interventions to the point of futility. These are some of the steps that could help to improve the health of individuals as well as our population: closer collaboration between medicine and public health; increased emphasis on health promotion and disease prevention; improvement of chronic illness care; increased emphasis on mental health services; and earlier shift to palliative care when cure is not possible.

3. Change how physicians are paid. Payment systems for physicians are complicated and are subject to being gamed for maximal profit by many physicians and their employers. Managed care of the 1990s placed many restrictions on care in an effort to increase the profits of HMO plans. Overvalued reimbursement of many specialized and procedural services is a major factor in the decline of primary care. By contrast, its services are time-consuming, require broad clinical competence, are more cognitive and less procedural, and are under-reimbursed. While there is room for various reimbursement methods, essential primary care services are best offered without cost-sharing with patients, and the wide gap between compensation of specialists and generalists must be narrowed.

4. Shift to evidence-based coverage decisions. We can no longer afford to offer services that don’t work, are not cost-effective, or are even harmful. But our present methods of deciding on coverage and reimbursement are heavily influenced by politics, lobbying, and the interests of industry and vested medical organizations. Many new technologies are brought to market without objective assessment of their benefits and value by disinterested experts. Other industrialized countries around the world have developed effective ways to apply the best available clinical evidence to this decision-making process, but market forces have resisted such approaches in this country.

5. Re-design primary care based on generalism and interdisciplinary team practice. Past ways of organizing primary care practice no longer work for a variety of reasons. Given the pressures of time and the complexities of practice today, many primary care physicians are burning out and not being replaced. The delivery of primary care services needs to be re-engineered, with primary care physicians seeing a smaller number of patients with more complex problems, working with other team members in their areas of expertise, and coordinating care being provided by consulting specialists.

6. Re-establish a generalist orientation in medical education. Despite the development of new education programs in medical schools and hospitals over the last three decades, the aura of specialization has dominated medical education. Medical school graduates have opted in droves for the increased compensation and more attractive life styles of non-primary care specialties. A physician workforce goal needs to be established for a 50:50 balance of generalists and specialists, together with financing changes that favor institutional change, changes in medical school admissions policies, and expanded scholarship and loan repayment programs for students and residents bound for primary care careers.

7. Create a new ethical environment of accountability in medical practice, education and research. We have a medical-industrial complex, wherein the higher the volume of services that is delivered to patients, the higher the revenues to the providers and suppliers. About one-third of health care services are either inappropriate or unnecessary, some even harmful. (Wennberg, JB, Fisher, ES, Skinner, JS. Geography and the debate over health care reform. Health Affairs Web Exclusive W- 103, February 13, 2002) This problem is driven by widespread conflicts-of-interest among physicians, industry, and others, as described in my 2008 book Corrosion of Medicine: Can the Profession Reclaim Its Moral Legacy? All past efforts to rein in these conflicts-of-interest have been ineffective, and the patient is at a disadvantage in evaluating what services are, or are not, worthwhile.

8. Expand primary care and systems-oriented research. The annual budget for the National Institutes of Health (NIH), with its focus on biomedical and disease-oriented research, is about 75 times that of the Agency for Healthcare Research and Quality (AHRQ), the principal source of federal funding for primary care and systems-oriented research. Given the urgency of building a better delivery system based on primary care, we need a far greater investment toward that goal.

9. Tighten regulatory processes and policies. Our regulatory apparatus is too industry-friendly, is understaffed, and needs more federal funding and independence from industry. Right now, the fox is in the hen house. One of many examples: an artificial hip manufactured by a subsidiary of Johnson & Johnson was designed to last about 15 years, but has been failing worldwide at unusually high rates after just a few years. It had been approved through a loophole with lax testing requirements. The company continued marketing its defective product even after whistle-blowing efforts by orthopedic surgeons, and the U.S. still has no tracking system to monitor the experience of artificial hips. (Meier, B. The implants loophole. New York Times, December 17, 2010: B1))

10. Increase protections for patients and physicians against medical malpractice liability. Patients need protection from medical injuries due to negligence while physicians need protection from frivolous lawsuits. But this issue is typically exaggerated (especially by conservatives) as a major cause of health care inflation. That is not the case. Though “defensive medicine” is common, the annual costs of the medical liability system make up only 2.4 percent of total health spending. (Mello, MM, Chandra, A, Gawande, A, Studdert, CM. National costs of the medical liability system. Health Affairs 29 (9): 1569-77, 2010) While this whole issue is immensely complicated, useful steps that will help to protect patients from injury and physicians from unwarranted liability for malpractice include: increased emphasis on patient safety in medical education and clinical practice; increased use of evidence-based practice guidelines as “safe harbors” for physicians; and increased use of arbitration.

Although the current political landscape is unfavorable for this kind of forward thinking, time will probably tell that what seems utopian now is absolutely required not too far down the road.
_____________________

Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011)

John Geyman, M.D.
Professor Emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program

We are indebted to the late Dr. Barbara Starfield of the Johns Hopkins School of Public Health for this basic definition of the four pillars of primary care: (1) first-contact care; (2) longitudinal continuity over time; (3) comprehensiveness, with capacity to provide care for the majority of health problems; and (4) coordination of care with other parts of the health care system. (Starfield, B. Is primary care essential? The Lancet 344 (8930): 1129-33, 1994) Dealing as they do with a broad spectrum of patients’ problems, generalist primary care physicians necessarily think and practice differently than specialists, who deal with a deeper level of knowledge and skills in a far narrower area.

These are some of the most common myths and misperceptions about the generalist primary care role in the U.S. today, together with brief responses to clarify them.

1. As a generalist, it’s impossible to know everything.
This is true—nobody can know everything. But the generalist’s knowledge is different from that of the specialist, both in kind, breadth and depth. This widespread sentiment reveals a fundamental misunderstanding about the nature of knowledge and information. It is based on the faulty assumption that all specialized knowledge must be vertical, in-depth knowledge about a narrow subject. Dr. Gayle Stephens, an early pioneer in the evolution of family medicine since the 1960s, reminds us that:

“None of the certifiable medical specialties were established on epistemological grounds. Most of them sprang up like Topsy and exist by virtue of political, economic, and technological factors that have little to do with a theory of knowledge. . . All of medicine is derivative, secondary, and applied.” (Stephens, GG. The Intellectual Basis of Family Practice. Tucson. Winter Publishing Company, Inc, 1982, p3)

2. Primary care deals with trivial content and problems.
Generalist physicians are attracted to the front-line nature of their work, dealing as they do with a wide spectrum of care spanning the entire life cycle (in the case of family medicine), medical emergencies, screening and prevention, diagnosis and management of acute and chronic illnesses, counseling and long-term care. They are prepared to definitively manage the majority of the problems brought to them, arrange for consultation with appropriate specialists when necessary, and then co-manage many patients with consulting specialists thereafter. A recent study comparing the relative complexity of patient encounters in three fields—general/family practice, cardiology and psychiatry—concluded that the practice of generalists is one-third more complex than that of cardiologists and five times more so than that of psychiatrists. (Katerndahl, D, Wood, R, Jaen. CR. Family medicine outpatient encounters are more complex than those of cardiology and psychiatry. J Amer Board Fam Med 24 (1): 6-15, 2011)

3. Anyone can do primary care.
Many specialists, with little experience, knowledge or understanding of primary care practice, denigrate it as “simple” and nowhere near as challenging or complex as their own specialty. Such a self-serving attitude often dates back to their own experiences in medical school, where they heard similar sentiments from some of their sub-specialist mentors with little of no experience in community practice.

In fact, generalist physicians today have three or more years of residency training after medical school, are willing and able to cope with the intellectual challenges and ambiguity of primary care practice, enjoy working closely with people, and have a mindset looking for patterns of illness beyond the shackles of arbitrary specialty boundaries.

4. Specialist care is better than generalist care.
Since our culture tends to worship technology and specialization, it follows that many Americans naturally assume that specialty care is of higher quality than that provided by generalists. A major review of the literature in 2007 attempted to answer this question, but yielded mixed results. Forty-nine studies compared the quality of care provided by generalists vs. specialists, but were limited by their focus on single discrete medical conditions, thereby advantaging specialists over generalists. We still don’t have a solid answer to this important question, since these studies failed to deal with multiple chronic conditions, little attention was paid to coordination and integration of care, case-mix adjustment was often inadequate, and characteristics of physicians’ practice settings (such as use of clinical practice guidelines and electronic medical records) were ignored. (Smetana, GW, Landon, BE, Bindman, AB, Burstin, H, Davis, RB et al. A comparison of outcomes from generalist vs. specialist care for a single discrete medical condition. Arch Intern Med 167 (1):10-20, 2007) At the macro level, however, a 2005 analysis of 100 ecological studies of the relative benefits of generalist vs. specialist care in various health care systems concluded that “primary care helps prevent illness and death . . .and . . . that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations.” (Starfield, B, Shi, L, Macinko, J. Contribution of primary care to health systems and health. Millbank Q 83: 457, 2005)

5. Since medicine has become so specialized, generalists are no longer needed.
Actually, there has never been a greater need in this country for generalist physicians rebuilding the deteriorating primary care infrastructure. Current projections call for a shortage of 45,000 primary care physicians by 2020 (Krupa, C. Physician shortage projected to soar to more than 91,000 in a decade. American Medical News. Amednews.com, October 11, 2010). If the 2009 health care reform legislation ever gets fully implemented, some 32 million Americans will be newly covered by health insurance (including 16 million on expanded Medicaid) in 2014. But replacements of our dwindling supply of primary care physicians are nowhere in sight. Already, only 42 percent of patients’ annual visits to physicians for acute medical problems are made to their personal physicians; all the rest are made to emergency rooms (28 percent), to specialists (20 percent), or to hospital outpatient departments (7 percent), often with difficulty in arranging follow-up care. (Pitts, SR, Carrier, ER, Rich, EC, Kellerman, AL. Where Americans get acute care: Increasingly, it’s not at their doctor’s office. Health Affairs 29 (5): 1620-28, 2010) So we’re facing a growing crisis in having generalist primary care physicians available for patients to see that they know. More to be expected—continued growth in the numbers of patients without a primary care physician who are forced to seek care from strangers through emergency rooms, urgent care centers and other facilities without access to the full benefits of primary care.

Adapted in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Health Care, 2011.

John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President of Physicians for a National Health Program

These are some of the major ways by which Americans are hurt by the growing deficit of generalist physicians:

1. Can’t get a primary care physician.
It is getting harder and harder to find a generalist primary care physician still open to accepting new patients. In Massachusetts, for example, the passage of legislation in 2006 expanding insurance coverage for many people exposed a critical shortage of primary care physicians. (Fitzgerald, J. State medical group sees severe shortages in 10 specialties. Boston Herald, October 20, 2010) Patients on Medicare and Medicaid have particular problems finding a physician willing to take them on due to low reimbursement through those programs. Under the banner of fiscal austerity, many states are cutting Medicaid to the bone. In California, for example, where Medicaid (Medi-Cal) covers one in five Californians, Medi-Cal payment rates for physicians and other providers have been cut by 10 percent to just $11 a patient visit (Corcoran D. Doctors say Medi-Cal reimbursement is too low. San Francisco Chronicle, August 4, 2011) Even if one has a primary care physician today, the likelihood of a continued relationship in the future is becoming increasingly clouded due to physician retirements, mobility among physicians, and changes of providers in insurer networks that often force changes of physicians.

2. No access to breadth of primary care.
People without a primary care physician don’t get access to the breadth of primary care anywhere else in our “system”. Specialists are not trained or equipped to provide preventive services across the board, care for acute and chronic problems for patients of all ages, continuity of comprehensive care for all medical problems for years, with knowledge and understanding of their patients’ family and community setting. Emergency rooms and urgent care centers can focus only on the most acute problem at the time, with little follow-up, while so-called “retail clinics” for walk-in care are limited to non-emergency and low-acuity problems. As a result, many of the potential advantages of primary care are not available to a growing part of our population.

3. Higher costs and unaffordability of care.
Specialty care costs more than primary care—a lot more, for a number of reasons. For new medical problems, specialty physicians have to start “cold”, without context or knowledge of the patient, often ending up repeating tests and procedures that have been done previously, charging more than primary care physicians, and in the case of multiple medical problems, typically having to call upon other specialists for care. Since primary care physicians know their patients better, they order fewer tests than specialists, and help to protect their patients from inappropriate and unnecessary care. (Schoen, C, Osborn, R, Doty, M, Bishop, M, Peugh, J et al. Toward higher-performing health systems: adults’ health care experiences in seven countries. Health Affairs (Millwood) 26: w 717-34, 2007)

4. Foregone necessary medical care.
Foregone care is widespread and increasing. These markers document this growing trend:

• In the last year, one in three Americans skipped care, did not fill a prescription, or get other care because of cost. (Parashar, A. Compared to other countries, U.S. patients have more access to specialists, less to primary care. Kaiser Health News, November 18, 2010)
• One-third of uninsured adults have a chronic disease for which they
don’t get needed care. (Wilper, A, Woolhandler, S, Lasser, KE, McCormick, D, Bor, DH et al. A national study of chronic disease prevalence and access to care in uninsured U.S. adults. Ann Intern Med 1249 (3): 170-6, 2008)
• Two million cancer patients are now foregoing necessary care each year due to unaffordable costs. (Weaver, KE, Roland, JH, Bellizzi, KM, Ariz, NM. Foregoing medical care because of cost: Assessing disparities in healthcare access among cancer survivors living in the United States. Cancer online, June 14, 2010)
•. The number of annual patient visits to physicians has declined sharply since the onset of the Great Recession in 2008. (Johnson, A, Rockoff, JD, Mathews, AW. Americans cut back on visits to doctor. Wall Street Journal, July 29, 2010: A1)

5. Decreased coordination and integration of care.
Coordinated and integration is a huge problem, especially for patients with multiple medical problems, the norm for older patients. The electronic medical record does not substitute for close communication between specialists for such patients. According to the Joint Commission on Accreditation of Healthcare Organizations, 80 percent of serious medical errors are associated with lack of communication or teamwork among specialists in hospitals. (Health blog. Joint Commission-Hospital Collaboration targets hand-offs. Wall Street Journal, October 21, 2010)

6. Decreased quality of care with worse outcomes.
Compared to those without primary care, patients with primary care receive earlier diagnosis and treatment of illness and better outcomes of care (Ferrante, JE, Gonzales, E, Pal, N, Roetzheim, RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 13: 408-14, 2000), including lower mortality rates (Baicker, K, Chandra, A Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs (Millwood) 23: w 184-97, 2004)`

Unfortunately, the essential role of primary care in any health care system is not widely understood. In the next post we will consider some of the many misperceptions about it, and how they represent barriers to building a better health care system in this country.

Adapted in part from my recently released book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans. Copernicus Healthcare, 2011, soon to be available as an Ebook on Amazon.

John Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
Past President, Physicians for a National Health Program

Here are just three of their unfounded claims, together with references from the health policy literature and recent publications that rebut their assertions:

• Re the alleged advantages of privatized Medicare, see my 2006 book (Geyman, JP. Shredding the Social Contract: The Privatization of Medicare. Monroe, ME. Common Courage Press, 2006), my extensive article in The International Journal of Health Services (Geyman, JP. Privatization of Medicare: Toward dis-entitlement and betrayal of a social contract. Intl J Health Services 34 (4): 573-94, 2004), a 2009 report by the Committee on Energy and Commerce (Committee on Energy and Commerce. New report highlights Medicare Advantage insurers’ higher administrative spending. Washington, D.C., December 9, 2009), a 2010 article in the Wall Street Journal on retrenchment of private Medicare plans (Johnson, A. Private Medicare plans are retrenching. Wall Street Journal, November 19, 2010: B1), and a recent article in The New England Journal of Medicine describing the failures of regulated competition among private insurance companies in the Netherlands and calling into question managed competition as a model for private Medicare plans in the this country. (Okma, KGH, Marmor, TR, Oberlander, J. Managed competition for Medicare? Sobering lessons from the Netherlands. N Engl J Med, June 15, 2011)

• Re the alleged advantages of private health insurance over single-payer national health insurance, see my 2008 book on the private health insurance industry (Geyman, JP. Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It. Monroe, ME. Common Courage Press, 2008), my extensive article in The International Journal of Health Services (Geyman, JP. Myths and memes about single-payer health insurance in the United States: A rebuttal to conservative claims. Intl J Health Services 35 (1): 63-90, 2005), and a 2009 report by the Congressional Research Service, The Market Structure of the Health Insurance Industry (Austin, DA, Hungerford, TL. The Market Structure of the Health Insurance Industry. Washington, D.C, Congressional Research Service, November 17, 2009).

• Re the claimed efficiencies of competition in health care, see a multi-year study by the Community Tracking Study showing the failures of markets to be more efficient or to enhance the quality of health care (Nichols, LM et al. Are market forces strong enough to deliver efficient health care systems? Confidence is waning. Health Affairs (Millwood) 23 (2): 8-21, 2004) and a recent article by Mark Weisbrot, co-director of the Washington, D.C-based Center for Economic and Policy Research (Weisbrot, M. Problems of U.S health care are rooted in the private sector, despite right-wing claims. McClatchy-Tribune Information Services, July 20, 2011).

Health policy is too important to leave to the biased, well-funded propaganda
machine of these “research” organizations that keep promulgating policies that have long since been discredited, either by their failing track record or legitimate research studies.

John P. Geyman, M.D.
Professor emeritus of Family Medicine, University of Washington
www.copernicus-healthcare.org

This is the first in a series of four posts that will describe this crisis, how it has progressed over the last 50 years despite all attempts to deal with it, together with why it matters to all Americans and what can be done about it. These posts are drawn in part from my latest book Breaking Point: How the Primary Care Crisis Endangers the Lives of Americans, just released by Copernicus-Healthcare and soon to appear as an ebook on Amazon.

Primary care is a term that many are unfamiliar with, often even including within the health professions. We’re talking here about generalist physicians and other health professionals working with them, in the ongoing care of unselected (not referred) patients of all ages for whatever problems they need to seek care. This is in the front lines of health care, for individuals and families, in their own community setting. General practitioners in earlier years represented this kind of physician. Since the 1960s, four other kinds of generalist physicians have evolved as various kinds of medical education programs have been developed—family practice (now family medicine), general internal medicine (for adults), general pediatrics (for children), and osteopathic physicians (with training that includes manipulative therapies).

Most advanced countries have at least 50 percent of their physicians as generalists at the foundation of their health care systems. While the U.S. had such a base until World War II, that number has declined over the last 60 years to less than 30 percent. And that number is dropping fast. Less than one in five U.S. medical graduates are now entering a primary care specialty, while most opt for better-paying, more attractive lifestyles of other specialties. (Pear, R. Doctor shortage proves obstacle to Obama goals. New York Times, April 27, 2010: A1) We now have a specialist-dominated system without anywhere near the number of generalists needed, as shown by Figure 1 in 2025. (Colwill, JM, Cultice, JM, Kruse, RI. Will generalist physician supply meet demands of an increasing and aging population? Health Affairs Web Exclusive, April 29, 2008, w 232-41)

In his recent article in The New Yorker, Dr. Atul Gawande, general and endocrine surgeon at Harvard Medical School, described the importance of the generalist in these compelling terms:

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later? Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.” (2) (Gawande, A. The cost conundrum: What a Texas town can teach us about healthcare. The New Yorker, June 9, 2009: 34-44.)

Advanced countries around the world with higher-performing health care systems than the U.S. have all build their systems on a solid base of primary, generalist care, readily available to patients for common health care problems where they live. Secondary care includes more specialized care for less common problems, while tertiary care deals with rare or unusual medical problems in university medical centers or other large urban hospitals. In most of those countries, specialists serve as consultants for particular medical problems, while primary care physicians provide ongoing continuity of care for all of their patients’ problems.

This is how a 2008 report of the General Accounting Office sums up the primary care crisis in this country:

“Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care—all hallmarks of primary care medicine—can achieve better health outcomes and cost savings. Despite these findings, the nation’s current financing mechanisms result in an atomized and uncoordinated system of care that rewards expensive procedure-based services while undervaluing primary care services.” (GAO. Primary Care Professionals: Recent Supply Trends, Projections and Valuation of Services. Washington, D.C. GAO-08-4721. Government Accounting Office, February 2008, p 15)

In our next post, we will see how our upside-down system does not work, and how it is responsible in large part for most of our system problems, whether at the level of individual health care or population-based care.

• By way of the individual mandate, insurers will gain 32 million new enrollees,most requiring government subsidies to either patients or employers.

• The drug industry avoided importation of drugs from other countries and again fended off any role of the government to negotiate drug prices, as the Veterans Administration does so well in getting prices down to about 58 percent of usual costs.

• Existing specialty hospitals, physician-owned facilities that allow physicians to “triple dip” their incomes as providers, owners and investors, were grandfathered in.
But that was only the start of a continuing series of compromises by the Obama Administration that further weaken the bill and add fuel to the accelerating rate of health care inflation. When any of the corporate stakeholders raised objections to one or another part of the “reform” package, their objections were generally met with industry-friendly concessions.

The government had little room to negotiate. Having falsely assured the public from the beginning that they could keep their insurance if they liked it, the government had put itself into a corner where it has to cater to the insurance industry. Otherwise, the market would be “disrupted”, resulting in many people losing their coverage.

Waivers have become the instrument whereby to further coddle the insurance industry, rendering less effective any “teeth” that are in the bill. In the last few months, there have dozens of waivers granted, watering down a number of provisions of the PPACA. Here are some examples:

• When insurers complained that they may have to exit the market if forced to offer coverage of sick children on their parents’ policies, the government obliged by allowing brief open-enrollment periods whereby such coverage would be unavailable for much of the year; insurers were also granted permission to raise premiums for sick children until 2014, to the extent that state laws allow. (1)

• Insurers are still free to set their own premium rates, with little effective restraint by a government which can mostly just protest large increases; most rate-
setting “controls” are at the state level, where regulators tend to be industry-friendly. Thus premiums may be hiked up to 40 percent in the individual market.(2)

• The industry has strongly resisted the law’s requirements to set their medical loss ratios (MLRs) at 85 and 80 percent, respectively, for large employer and small employer/individual plans. That would force them to pay out at least 80 or 85 percent of their premium revenue on medical care. But what counts as “medical care”? The industry lobbied hard for a broad interpretation of that question, to include a number of non-medical expenses, even extending to commissions of insurance brokers. The latest rules, as recommended by the National Association of Insurance Commissioners and adopted by the Department of Health and Human Services (HHS), affect about 75 million people (11 million with individual policies, 24 million with small group coverage, and 40 million with large employer coverage). The insurance lobby won a number of concessions, including counting expenses of quality assurance as medical costs, allowance to deduct many of their taxes from their total premiums before calculating their MLR, and the ability to appeal for a lower MLR standard for up to three years in states where “there is a reasonable likelihood that market destabilization could harm consumers”. Four states have already sought such adjustments—Georgia, Iowa, Maine, and South Carolina. (3)

• Many insurance plans, including most large employers, are already exempt from the PPACA’s provisions. These plans have been “grandfathered in” without PPACA requirements, and have even been given other ways (eg. switching carriers) to keep that status.

• A recent ruling by HHS allows more than 100 employers and other insurers to retain very low annual limits of coverage (eg. only $2,000 a year, hardly qualifying as insurance). Employers such as McDonald’s Corp., after warning regulators that it might have to drop coverage for 30,000 hourly workers, handily won this concession for their “mini-med” policies. (4)

According to economists at the Centers for Medicare and Medicaid (CMS), health care spending will not be cut by the PPACA. By 2019 they expect that U. S. health spending will reach $4.6 trillion, accounting for almost 20 percent of GDP. By then spending on private health insurance will exceed $600 billion a year (32 percent of all health care spending). (5)

As health care inflation proceeds apace, employers are passing on more costs to their employees. Prices continue to soar throughout the system, even accelerating as hospitals and physician groups gain consolidated market clout. This leaves insurers and employers in a weaker negotiating position. Health insurance and care get less affordable every day for much of our population. And federal subsidies under PPACA are more than three years off in 2014, as is Medicaid expansion.

So the health care crisis continues unabated as proponents of PPACA and a defensive Administration posture how much it is helping us. The urgency and stakes for real reform just notch up with each passing month and year. Despite the losses of progressive policies in the recent midterm elections, there is one bright ray of hope in three states—Vermont, California and Hawaii—where the new leadership is supportive of real health insurance reform—single-payer universal coverage without exploitive profiteering by a dying insurance industry kept alive only by government subsidies of one kind or another.

References:
1. Pear, R. U. S. to let insurers raise fees for sick children. New York Times, October 13, 2010.
2. Ostrom, CM. Steep rate hikes on way for individual health insurance. Seattle Times, September 6, 2010.
3. Pear, R. New rules tell insurers: spend more on care. New York Times, November 23, 2010: A22.
4. Adamy, J, Johnson, A. Rules eased for some health plans. Wall Street Journal, November 23, 2010: B1.
5. Adamy, J. Health outlays still seen rising. Wall Street Journal, September 9, 2010: A7.

Adapted in part from Hijacked! The Road to Single Payer in the Aftermath of Stolen Health Care Reform, 2010, with permission of the publisher Common Courage Press.