from the pages of../

Health Care

Primary Care or Bust

By Scott H. Failor


President Clinton expresses "unwavering commitment" to universal health care coverage for all Americans. He does recognize that universal coverage must involve increasing primary care resources and decreasing dependence on specialists and "emergency care," yet these concerns have taken a back seat to the insurance debate. If the current "specialist-emergency room" based health care model is not converted into a primary-care, community based model, then the current crisis will most probably worsen.

Universal coverage will mean tens of millions more health care consumers (patients). The vast majority of these new consumers, most low income, will have limited options. The newly insured could seek care with a non-profit primary care clinic, if one exists in their community. Yet these clinics are under funded and under staffed. Most new patients will be forced to visit hospital emergency rooms seeking nonemergency care. Emergency rooms will be further stressed in their capacity to provide effective emergency care.

Currently, insurance reimbursement rates for providers who care for low income clientele are lower than actual costs of care. A report released by the Kaiser Family Foundation, and reported in the March 18, 1993 Washington Post, explains how two million low-income adults ages 18-64 were denied medical care by a doctor or hospital in the first half of 1992. The main reason for denial of care, the report maintains, was the very low fees many states pay for Medicaid patients. These millions of underinsured, along with the 37 million uninsured Americans, have few health care options as hospitals shut their doors to low or no reimbursement.

Unjust low income insurance reimbursement rates, both private and public, affect all medical facilities. The vice-president of St. Joseph Medical Center in Burbank, California explained in a July 1992 Consumer Reports that "Hospitals find themselves jockeying for geography. If you can be promised service areas that include freeways, and therefore get trauma cases covered by auto insurance, you can break even. If you don't include freeways..." caring for the uninsured and underinsured is financially infeasible. St. Joseph Medical Center was forced to close its trauma center because the annual losses of $1.5 million threatened the survival of the entire hospital.

Low income communities are disproportionately hard hit by low reimbursement rates and the dissolution of health care facilities. Small hospitals and health clinics operating in underserved areas are forced to survive on these same reimbursement rates that force larger providers to shut down. Loss of these health care centers affect communities deeply, depriving citizens of essential health care. These closures shift the financial burden of caring for the poor to remaining health care institutions in or near the community, creating longer waits for appointments and a decrease in the quality of care.


The Westside

To illustrate this point, take the example of the Westside Community Health Center in Santa Cruz, California where I serve on the staff and as a member of the Board of Directors.

The "Westside" is one of two primary care health clinics in Santa Cruz county that accepts an unlimited number of MediCal patients. The county has a population of approximately 200,000 people, a sizable percentage being monolingual Mexican and Central American immigrants, and poor working class citizens. This community based non-profit clinic has served the Santa Cruz community for 11 years with an expressed mission of serving the entire population regardless of social status.

In the 1992-93 fiscal year, the clinic served a total of 4,000 patients in 10,000 visits. The Westside's patient load has more than doubled since 1989, and the demand for affordable, quality health care continues to grow at astronomical rates. In just the first 6 months of the 1993-94 fiscal year alone, the Westside clinic saw 1,446 new patients.

While it would seem that this increase in number of visits would increase the health center's income, paradoxically the more patients the clinic sees, the less net income for the clinic.

One of the main reasons for this discrepancy is the reimbursement rates from MediCal. From 1989 to 1994, the percentage of clients using MediCal increased from a previously stable 33 percent to 60 percent. Reimbursement from MediCal pays only about 45 percent of the cost of patient care. This means that the health center sustains a 55 percent net loss for each MediCal patient treated. Furthermore, by offering a sliding fee scale that offers the same quality health care at a discounted price to low-income patients without private insurance or MediCal, the clinic is among the very few local providers willing to meet the needs of the working poor.

The economic problems experienced by community-based, non-profit clinics stem from practicing the very ideals reform minded politicians are preaching: low costs, universal access, quality care, and preventative medicine. Current federal and state government economic priorities, and MediCal reimbursement rates punish providers and institutions who care for the poor. This is the main reason why very few providers still accept MediCal, and why the few providers committed to serving the entire population are forced to survive by cost shifting, or competing with others for scarce foundation grants, corporate funds, and government allocations.

Only about 3 percent of Westside's patients pay the full cost of their visit. Due to very strict cost controls in all areas of operation, and the good will of an idealistic and committed staff, the clinic has survived thus far. But as poverty levels increase, and demand for MediCal visits increases, the losses endured by Westside are becoming too much to bear.

At this rate, the clinic might be forced to shut its doors by the end of the fiscal year, leaving only one or two primary care nonprofit clinics in the county. If Westside closes, the burden of care will shift to the local hospital's emergency room and the county health services clinic. Both these facilities are already overburdened. The local county health services already has difficulty scheduling prompt medical care for common sick visits such as ear aches, respiratory infections and bladder infections. Most likely, low income citizens will be forced to use local emergency facilities for primary medical care. This translates into astronomical costs and lack of continuity in care.

If health care reform implements a universal access policy without addressing the deficit of primary care clinics, those still in existence will be even further overburdened, resulting in an accelerated downward spiral in the quality of care. Without adequate reimbursement rates, these clinics will undoubtedly be forced to shut their doors.


Health Care Reform

Americans spend more on health care than any country in the world. In 1990 the United States, with less than 5 percent of the worlds population consumed 41 percent of the global health resources. One would expect the 5 percent consuming 41 percent of the global health care pie to be fairing very well in terms of health statistics. Yet as a U.S. Government report to the Organization for Economic Cooperation and Development (OECD) countries explains, "Despite the highest health expenditures in the world, the United States does not perform particularly well in terms of gross health outcome measures. For instance, in 1988 the United States had a life expectancy at birth of 71.5 years for males and 78.3 years for females, and infant mortality rate of 10.0 per 100,000 births. Compared with the other OECD countries, it ranked 17th in male life expectancy, 16th in female life expectancy, and 20th in infant mortality." In 1990 the United States spent nearly $2,800 per capita on health care and ranked 11th in the world for life expectancy. For comparison, Greece spends a total of $358 per capita on health care and achieved the same life expectancy as the United States, 76 years. (The Chinese had a total health services budget that amounted to $11 per capita, and achieve a 69 year life expectancy .)

According to a Congressional Budget Office (CBO) study released in July 1993, the current reform package being offered by the President offers little relief, and in many ways compounds the problems. The report, as quoted by the Washington Post, states that by the year 2000, if the current system is left unchanged, "39 million people would be uninsured and health care spending would rise to $1.7 trillion" The report goes on to explain that "If the nation adopted a `managed competition' approach, which the Clinton administration appears to favor, costs would be $19 billion more in the year 2000 than under the current system, while more than 25 million people would remain uninsured at the end of the decade" (emphasis added).

Of all the health care reforms proposed so far, according to the CBO report, the Single Payer, Canadian-Style plan would hold down costs most and provide health insurance to all Americans by the end of the decade. Yet while the Single Payer plan is by far the best, most meaningful reform proposal regarding insurance coverage, even if by some democratic miracle a Single Payer plan was implemented nationally, the United States simply does not have the necessary health infrastructure to provide quality care for the millions of "health consumers" entering the "health care market," nor would runaway health care costs be contained. The CBO report states that "even if the nation adopted a Canadian-style system, health care spending would nearly double by the year 2000--to $1.55 trillion from $830 billion last year."

It is clear that, while meaningful insurance reform must be part of the solution, it is not the whole answer. Meaningful reform of the current system of care delivery must also be promoted on the grassroots level if costs are to be controlled and access to health care expanded to the entire population. As in the insurance debate, there are powerful interests that will fight reform in the area of delivery of care (i.e. expanding access to and promotion of primary care).

Trying to regulate and control, (and in the case of the insurance industry dismantle) some of the most powerful and influential interests in the country, and indeed the world, will require a prolonged and fierce social struggle. This battle will undoubtedly take decades. The current crisis is not the product of benign neglect or innocent error. The U.S. health care system has evolved to where it is today because very powerful interests have shaped it as such to insure huge profits. Changing these priorities will not be easy.


Public Funding

Under the current system, huge health care corporations in the form of hospitals, and expensive specialist physicians, dominate the administration of care. One of the major factors that has driven up health care costs and denied access to health care to millions of low-income Americans is this current model of providing care.

During the 1950s and 1960s, the American tax payer funded hospital development, and through the 1970s tax dollars, in the form of increased Medicare fees, allowed hospitals to expand and renovate facilities. During the 1980s, however, as Government subsidies (i.e. public tax money) dropped to fuel defense spending and other federal and state priorities, the hospitals started closing their doors to low income medicaid patients. In order to attract the highest quality physicians, along with high-income patients and physician referrals from the community, hospitals started to engage in what the OECD report refers to as "a medical arms race, in which each [hospital] competes to own state-of-the-art technology. "

This phenomenon increases health care costs, placing health care out of reach of millions of Americans. The net result is that the publicly created hospitals of the 1960s and 1970s, ate up over 38 percent of the $666 billion Americans spent on health care in 1990, and raked in $7 billion in private profits. The fact that the majority of care being performed within these centers is administered by medical specialists, as opposed to general practitioners and primary care doctors, is one main reason for runaway costs and decreased access.

Most medical treatment, over 75 percent in fact, does not need a specialist or a hospital. Patients with sprained ankles do not need to see orthopedists, those with ear aches need not see an otolaryngologist, and individuals with urinary tract infections do not need to see urologists. All these patients can be treated more wholly, efficiently, and at a fraction of the cost by a primary care practitioner. Richard A. Smith, a clinical professor of family practice at the University of Hawaii points out in a March 8 editorial in the San Francisco Chronicle that "Estimates of savings possible, through increased use of such mid-level providers working with doctors to provide quality care, range from $23 billion to $90 billion annually, which is 2.5 to 10 percent of our health care costs." The cost would be even lower in a community based, primary care non-profit clinic.

Since it is generally agreed that vastly expanded primary care is needed, how did we end up with so many specialists and hospitals making so much money, and so few primary care providers and community based clinics? The reason for the dramatic increase in specialists and the near disappearance of primary family care providers has actually very little to do with the needs and demands of the population.


Private Profits

The vast majority of the 5.5 billion federal medical research budget goes towards the training and support of specialists and their research, with predictable results: the number of specialists has increased and continues to climb. For example, between 1965 and 1990 the number of gastroenterologists has grown by 1,000 percent; cardiologists by 900 percent; neurologists by 325 percent; and plastic surgeons by 300 percent. During this surge in the number of specialists, the number of general care physicians grew by only 66 percent.

This prioritizing of federal funds, unfortunately, has to do with the development of technologies as they relate to profitability, and not health care as an end in itself. The federal biomedical research and development grants (all tax payers' money) fund the domestic technology race with the dual purpose of cornering domestic markets for high-tech health care that translate into high level private profits, and securing intellectual property rights in the international market for new health care innovations.

An April 7, 1992 Wall Street Journal article reported that U.S. National Institutes of Health are engaged in "the biggest race for property since the great land rush of 1889...staking U.S. patent claims to thousands of pieces of genetic material--DNA--that NIH scientists are certain are fragments of unknown genes. "The purpose of this property race" is to ensure that the U.S. health industries dominate the biotechnology markets, which is expected "to be generating annual revenue of $50 billion by the year 2000," according to the Journal. The cornering of the international biotechnology market on a vast array of life-saving technologies is, in effect, controlling the essentials of life itself, a very profitable proposition.

The New York Times business pages observed that "Basic biomedical research has long been heavily subsidized by United States taxpayers" and that "high-tech pharmaceuticals owe their origin largely to these investments and to Government scientists." Keep in mind, these scientists are also funded by billions of U.S. taxpayer dollars.

In the pharmaceutical industry, for example, prices of the 20 most used prescription drugs rose at four times the inflation rate from 1984 to 1991. Profits in the tens of billions of dollars were secured for the drug companies, while driving up the cost of health care for the average citizen. It is estimated that private health insurance and medicine for profit cost Americans $138 billion in 1991 alone, according to health care analysts Steffie Woolhandler and David U. Himmelstein reporting for In These Times. This cost did not increase levels of care or the quality of care.

To get an idea of the magnitude this number, keep in mind that the total combined budgets for AFDC (Aid to Families with Dependent Children), Food Stamps and Head Start, plus most of the budget for employment and jobs training total only $43 billion. For an international perspective, a 1993 World Bank Development Report reported that only $10 billion would be needed to fund the public health care essentials in 40 of the worlds poorest countries, reducing disease by 32 percent among more that 3 billion people. The report, as cited by the July 7th Washington Post, contends that "Nearly 2 million children die every year of illness such as measles that can be prevented by cheap vaccines," and that "In all, 7 million adults die each year of diseases that can be inexpensively prevented or cured, including tuberculosis, according to the World Health Organization." One of the Bank's main recommendations for alleviating this desperate situation is reallocating health resources from emergency treatment care to primary and preventive care.

James E. Hug, the executive director of the Center for Concern in Washington DC, whose article "Health Care: a Planetary View" appeared in the December 11, 1993 issue of America, recognizes that if the United States meaningfully reforms its nearly $1 trillion health care sector, it could easily provide the $10 billion "that would provide the basic public health and essential clinical services that would be life saving for billions of the world's poorest," an act that he characterizes as true superpower leadership.


Private Profits = More Specialists = Less Primary Care

These federal and corporate priorities are largely responsible for the decline in the number of primary care practitioners. The natural by-product of federal (public) subsidy of the biomedical industry is the medical specialist. The immediate payoffs for those research and development institutions responsible for the education of the next generation of doctors are bigger, more expensive buildings and equipment, the acquisition of world renowned faculty, and prestige and wealth in general. This upward spiral results in skyrocketing tuition and debt for medical students, who then aspire to huge salaries. These students are thus exposed to almost overwhelming pressure to choose a career in prestigious and highly paid specialized medicine, or research and development.

With the federal government pouring about $10 billion annually into biomedical research and development, a measly $100 million gets diverted into primary care research. It is little surprise that medical students overwhelmingly choose the specialist path. The statistics speak to this trend: in 1992 only 15 percent of graduating medical students went into primary care medicine.

Medical students well know the results of the lack of funding for primary care. An Ohio family doctor responding to a professional survey sums it up like this: "Why bother with 60-70 hour work week, constant phone calls, all night emergency room visits, poor reimbursements, demanding patients, the need for instant exact decisions...concerning a million possible diseases, when you can `specialize' in one organ, get paid $500 for a 15 minute procedure, only need to know a dozen drugs and side effects, and work part time?"

It is exactly this reality, sparked by ill-founded priorities at the federal and corporate level of mixing health care with profits seeking, that has created a massive deficit in the number of primary care practitioners needed to meet the needs of the population.


Non-Profit Primary Care

The community based, non-profit primary care model is a blueprint in the area of cost containment, quality, and access. The non-profit clinic is not in the business of health care for profits. This fundamental shift in and of itself contains costs. In no way should this mean that clinic staff and providers are destined to a life of poverty. Within this framework there is ample room for reasonable material compensation.

Furthermore, the community clinic model has a central emphasis on the utilization of high quality primary care practitioners. Many of these clinics use mid-level practitioners such as physician assistants, nurse practitioners, and interns, who work under the supervision of a physician.

This "mid-level" position was created under the Kennedy administration in the early 1960s as a means of providing needed health care services in underserved areas of the county, namely in rural and inter-city communities. Today, mid-level practitioners are increasingly common providers in hospitals, walk-in urgent care chains, and community clinics. They are effective providers of quality care and are fully competent providers of everything from gynecological exams to pediatric care, from preventative health education to acute sick care. And they provide these primary care services at a fraction of the cost of specialists.

The mid-level practitioners and few remaining general, primary care physicians make up todays ranks of the "family doctors" that 50 years ago was 87 percent of health care providers. These providers can treat at least 75 percent of all patient illness, while the remaining 25 percent in need of specialized care are referred to specialists. It is generally agreed that the United States needs to bring into proportion its number of primary care physicians and specialists. As the government report to the OECD states, of the medial doctors in practice currently in the United States, "about 33 percent are primary care physicians (family practice, general pediatrics, and internal medicine) and the remainder are specialists. There is concern that the proportion of primary care physicians will continue to fall in the coming decade. The United States has a much higher percentage of specialists than do other OECD countries." It is generally recognized that a 50-50 ratio of specialists to primary care physicians is an adequate and healthy balance.

The "official" Clinton plan does recognize the benefit and need for promotion of primary care providers. But unless reform minded politicians are willing to transform the current system that undercuts primary care, reform will most likely be cosmetic. After all, corporate and government interests are largely parallel, with the government funding corporate advancement and profit.

Furthermore, the Clinton plan fails to recognize the need for special and urgent promotion of primary care, community based clinics. The community clinic model shifts the focus away from ad-hoc treatment. Patients are seen in the community setting where health care is delivered in an atmosphere of comfort and familiarity. This model empowers the patient through education and the fostering of trusting relationships, not just treatment. The entire staff functions as a team intent on preventing minor problems from becoming major ones. Citizens know and feel that the clinic is there to serve them. Clinic staff and mission reflect the cultural composition and economic needs of their particular community. Continuity of care is commonplace. Trusting patient provider relationships are established. Education and preventive medicine are at the forefront. Well-care and counseling programs are encouraged that discuss, monitor, and work to modify lifestyle behaviors (i.e. smoking, drinking, diet) that can lead to serious illness.

The federal and state governments must reverse their current policies of near exclusive promotion and support of high technology medicine and specialization which are in the pursuit of private profits. Our government must actively invest in grassroots nonprofit health care. To insure that this necessity is indeed met, the growing popular health care movement must actively push for health care reform as well as it has demanded insurance reform. It is essential to our nation's well-being to promote the non-profit, primary care community based model.

Scott Failor is active in primary health care and the single-payer movement..