Applied Evidence

The health care problem no one’s talking about

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While the nation focuses on expanding health coverage, growing numbers of insured Americans lack access to primary care. We’ve identified 8 barriers—and the means to overcome them.



As the nation moves closer to a health reform bill designed to extend coverage to the vast majority of the uninsured, a key concern is being overlooked: Simply having health insurance—crucial as that is—is not enough. People also need access to care, particularly to primary care. Yet a growing body of evidence suggests that even among insured Americans, access to primary care is on the decline.

Consider the following:

  • In 2005, more than 56 million Americans (nearly half of whom had some form of coverage) were “medically disenfranchised”—lacking sufficient access to primary care services. Two years later, that number had grown to 60 million.1
  • In a 2006 national survey, little more than 1 in 4 adults (ages 18 to 64) said they could easily reach their doctors by phone, get after-hours care, or schedule timely office visits.2
  • The number of medical school graduates in the United States choosing careers in family medicine fell from 2340 in 1997 to 1132 in 2006; during that same period, the percentage of internal medicine residents entering primary care dropped from 54% to 20%.3
  • In 2008, nearly 30% of Medicare beneficiaries seeking a new primary care physician (PCP) reported difficulty finding a doctor—a 17% increase since 2006.4

A shrinking pool of primary care physicians

Compared with other Western nations, the United States has a smaller proportion of its physician workforce engaged in primary care.5 Shortages of PCPs already exist in numerous states, with Alabama, Alaska, Florida, Kansas, Mississippi, Missouri, Oregon, South Carolina, and Utah among them.1 In the decade ahead, the Council on Graduate Medical Education, among other professional groups, expects the shortages to become more widespread and more severe.

Recruiting PCPs is increasingly difficult—something that comes as no surprise to physician recruiters. Merritt Hawkins, a large physician recruitment firm, reports that in 2005 the number of searches for open positions for PCPs exceeded searches for specialists for the first time.6 And in 2006, nearly half of all primary care residents were contacted by recruiters more than 50 times. In a survey of physician groups that same year, 94% of respondents ranked either internists or family physicians as the most difficult to recruit.7

Nurse practitioners (NPs) and physician assistants (PAs) have been important contributors to the primary care workforce, but they, too, may soon be in shorter supply. That’s especially true of PAs, given that less than one third (31%) of them are choosing careers in adult primary care.8

Quality of care pays the price. Ironically, the shrinking pool of PCPs coincides with the growing recognition of the importance of the patient-centered medical home. There is increasing evidence, too, of the link between lack of access to primary care and higher mortality rates9 and poorer outcomes.10 Lack of access appears to have an adverse effect on health care spending, as well. While the administration searches for ways to lower the cost of care in order to pay for the expansion in coverage, directors of health plans and medical groups expect medical spending to rise as the looming PCP shortage leads to greater use of specialists and more emergency visits.11

A broader look at inadequate access

The PCP shortage alone, however, is not the whole story. A number of other potent factors related to, but not the direct result of, the shortage contribute to the growing inability of insured Americans to have timely access to primary care. Chief among them are a mismatch between demand for appointments and physicians’ capacity to provide them, limited after-hours care, and organizational problems in primary care practices. We’ve identified the following barriers—and the policy changes and shifts in physician culture that are needed to overcome them.

BARRIER #1: Panel size

The average full-time primary care practitioner has an estimated panel of 2300 patients12—too many for a single physician to provide adequate patient care for, according to a recent study.13,14 Some practices have excessively large panels because they’re located in areas with a shortage of primary care providers. (In an area with 25 PCPs per 100,000 population, for instance, the average panel size would be 4000.) Other practices accept too many patients in order to stay afloat financially. In either case, a situation in which the demand for appointments exceeds the available time slots impedes a patient’s ability to get timely care.


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