By Jonathan Michels
Jacobin, January 19, 2022
Nightmare scenarios like these owe in part to the nation’s shortage of primary care physicians, which has made it nearly impossible for people to obtain preventive services or to secure an appointment with their provider quickly enough to receive the specialty care that might have enabled them to keep their limbs.
Thankfully, we’re beginning to see more investment in addressing the nation’s primary care shortage. In March of 2021, when he signed the American Rescue Plan, President Biden directed $1 billion to a program called the National Health Service Corps (NHSC). Not many people know about the NHSC, even though it’s been around since 1972. The NHSC commissions medical, nursing, dental, nurse practitioner, and physician assistant students to practice primary care in designated underserved areas, both rural and urban. In return, NHSC recipients receive student loan reimbursement or financial assistance to pay for college.
Before enrolling in a physician assistant graduate program, I worked for fourteen years as a health care worker at two of the largest medical centers in North Carolina. I know firsthand how a lack of primary care services leads to patients suffering from bankruptcy, chronic disease, avoidable surgery, and even death.
I applied for an NHSC scholarship because I saw the program as a way to deliver quality care to underserved patients, and a once-in-a-lifetime opportunity to serve in an organization whose mission actually aligned with my own values and beliefs: principally, that health care should be a public good. When I graduate in 2023, I will practice medicine among the largest cohort in the National Health Service Corps’ nearly fifty-year history.
Although it’s admittedly much too small to remedy America’s dysfunctional health care system, socialists should look to the NHSC as a model for universal programs like tuition-free college and as a way to focus our health care system around meeting human needs rather than the whims of the free market. Additionally, members of the NHSC are primed to take a leading role in the Medicare for All movement.
An Oasis of Humanity
In 1972, the NHSC commissioned its first twenty “officers,” most of them doctors, to treat patients in communities suffering from physician shortages. The ultimate aim of the program, however, “was to ‘sensitize‘ NHSC doctors to the health needs of the poor and increase the chances that these doctors, after their tours, would choose the psychic satisfaction of treating the needy over the financial rewards of practicing in more affluent communities.”
Although the demographics of the NHSC program grew to include an increasing proportion of mid-level practitioners, social workers, and mental and behavioral health professionals, the program’s commitment to meeting basic human needs is unchanged. Today, the NHSC remains a little-known oasis of humanity within the United States’ tapped-out, profit-driven health care system.
One study by the Kaiser Family Foundation found that federally funded community health centers serve nearly 26 million children and adults — roughly one in twelve Americans — in more than 10,400 urban and rural locations. Nearly half of all patients receive Medicaid. In some areas, these health centers are the only places one can go to receive primary care services like vaccinations and basic health screenings that have shown to improve health outcomes and lower the risk of disease.
Service corps members work to improve the health of thousands of Americans each day, but in 2000, researchers estimated that the program still met “only 12 percent of the need for primary health providers in underserved areas.” The increased capacity of the program afforded by the American Rescue Plan will likely improve that figure, but it won’t be enough to remedy the overwhelming deficiency in primary care providers, which is only expected to worsen in the next decade due to a combination of retiring physicians and a growing elderly population. The United States may be short as many as 55,200 primary care physicians by 2033, according to a report conducted by the Association of American Medical Colleges.
One of the main reasons American medical students forego careers in primary care is the exorbitant cost of medical school tuition. The median debt level of medical students is $200,000, possibly more at a private institution. The prospect of crushing debt prompts students to specialize in higher-paying fields like radiology and orthopedic surgery.
New York University Medical School eliminated tuition in 2018 in the hope that more students, relieved of their heavy debt burden, would opt to work in less lucrative areas of medicine like primary care. The NHSC goes a step further by directly placing providers in the communities where they are needed the most. And it doesn’t rely on the charity of rich donors. It’s funded by the public and for the public, just like the larger programs that will be necessary to remedy the larger problems at play, namely Medicare for All and tuition-free college.
The creation and expansion of the NHSC are genuine achievements, but other countries are able to accomplish even more with even fewer financial resources at their disposal. Even in the face of a devastating economic blockade, Cuba shows the extraordinary heights a society can reach when it prioritizes public health.
Cuba’s Latin American School of Medicine (ELAM) offers free education to students from all over the world, including the United States. “While graduates from US medical schools leave saddled with six-figure debts,” wrote Medea Benjamin in Jacobin, “the only debt ELAM students have is a commitment to practice medicine in low-income and medically underserved communities.”
Sounds a lot like the NHSC — except Cuba’s commitment to public health extends far beyond primary care. The result is that Cuba produces more doctors per capita than any other nation in the world, with health outcomes that rival those in far wealthier countries. In addition, the country’s “army of white coats” routinely deploys into underserved areas even outside of its own borders, risking their lives for strangers in order to stave off grave health crises ranging from Ebola to COVID-19.
The NHSC is operating at nowhere near this scale, but it gives us a glimpse in an American context of what’s possible — and ironically, despite the United States’ unceasing attacks on Cuba for over half a century, could inspire us to strive for more.
Our Own Army of White Coats
In the short term, there are several things that can be done to blunt the United States’ shortage of primary care providers. One solution is to find creative ways to retain NHSC providers who are already practicing primary care beyond their defined service obligation. Another option is to increase funding for the NHSC in an effort to enlarge its field strength.
These measures could not only address the primary care shortage, but might also strengthen the movement for Medicare for All. The recent expansion of the NHSC workforce may not be the sweeping social change that many of us hoped might emerge from the carnage of the pandemic, but it could represent one of the best opportunities we have in marshaling medical workers in support of a universal, single-payer program.
Transformative health reform like Medicare for All is unlikely to pass in the United States without the support of health care workers who understand that our greatest health victories have been won through building public infrastructures to protect and sustain our health. What if NHSC providers’ commitment to service could be used to motivate them to move beyond the arm’s length distance that clinicians are encouraged to keep from their patients, and instead join them and their coworkers in advocating for Medicare for All?
This hands-on approach toward raising consciousness has radicalized many health workers and clinicians in the past, and is still the answer today. Conservative physicians with the British Medical Association stymied efforts to nationalize health care in the UK throughout the 1940s. But several decades of practicing within the National Health Service inculcated doctors and residents to the point where they are now willing to take collective action to defend it against further attacks.
Our own history can also be instructive. Six years before the creation of the NHSC, a cadre of American doctors, nurses, and social workers with the Medical Committee for Human Rights (MCHR) volunteered to treat underserved communities in the Jim Crow South. In an effort to provide a long-term solution for the lack of primary care services endemic to the South’s medical apartheid system, local health care workers and community advocates working alongside MCHR members formed the country’s first federally funded health center in 1965. Thousands of other community health centers followed, many of them the same clinics where NHSC recipients currently provide primary care.
The MCHR eventually developed into a national network of health workers focused on securing a universal, national health program. Doctors like Quentin Young used their credibility as caregivers to mobilize their colleagues and the public in opposition against pernicious organizations like the American Medical Association and inspired generations of other health workers to do the same.
NHSC recipients took their first step toward acknowledging the need for a system that treats health care as a human right rather than a commodity when they signed up to practice primary care in underserved communities. The human solidarity that the NHSC elicits is an outlier at the moment, but it could provide an example of how we can transform a system intent on extracting cold currency from caregiving into one of service and sacrifice for the public good.