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See Inside October 2010

How Primary Care Heals Health Disparities

The U.S. health care system needs to focus more on general care and care coordination



Horacio Salinas Trunk Archive

The U.S. outspends all other industrial countries on health care, and yet we do not enjoy better health. Quite the opposite: an American baby born in 2006 can expect to live to 78—two years less than a baby born across the Canadian border. Out of the 30 major industrial countries, the U.S. ranks 28th in infant mortality. A large part of the gap in infant mortality can be traced to high infant death rates in certain populations—particularly African-Americans, who make up about 13 percent of the total population. In 2005 infant mortality for non-Hispanic blacks in the U.S. ran to 13.6 deaths per 1,000 live births compared with 5.76 deaths per 1,000 live births for non-Hispanic whites. The root causes of such disparities—which include differences in education, environment, preju­dice and socioeconomic status—are notoriously intractable. 

An easier fix may be under our noses: primary care. The idea is to have a clinician who knows your health history, will continue caring for you over the long term, and can recommend specialists and coordinate your treatment if you need to see them. Primary care can handle the health problems that most people have most of the time.

Research confirms the value of such care for the general population. The greatest benefits come to poor and socially disadvantaged groups, but they also extend to the well-to-do. Indeed, the need to strengthen primary care in the U.S.—making it more available—is one of the major tenets of the health reform laws that were enacted this past spring. A decline in availability in recent decades is a big reason why U.S. health has lagged behind that of so many other wealthy nations.

Primary care used to be the only game in town. In the late 19th century a family would rely on the same person (not always a doctor) to deliver babies, monitor and treat coughs and fevers, salve pain, comfort the dying, and assuage the grief of loss. Only the poor and the desperate went to hospitals. That changed in the 20th century, as advances in medical technology and in the education of physicians and nurses made hospitals safer places to be.

After World War II, Americans began associating medical progress with specialization. (In Europe, by contrast, the rebuilding effort led many nations to focus on general care—an emphasis that continues today.) The phrase “primary care” was invented in the U.S. during the 1960s in an effort by pediatricians and general practice physicians to resist the pull toward specialists. That effort failed; now only one third of U.S. physicians are primary care doctors—compared with about half in other industrial countries.

Primary care increases life span and decreases disease burden in part because it helps to prevent small problems, such as strep throat, from becoming big ones, such as a life-threatening infection of the heart. Having a regular clinician of that kind makes you a better patient because you trust the advice you receive and so are more likely to follow it; it also gives you access to someone who attends to the whole person, not just one body part. In addition, having someone to coordinate your care can be critical if you have multiple providers—as, for example, when you leave the hospital. (This coordination task is very different from the managed care trend of the 1990s that, under the guise of care coordination, turned many providers of primary care into gatekeepers who, in fact, mostly denied care.)

The many benefits of primary care show up in a range of research. Studies in the 1990s showed that those parts of the U.S. that had more primary care physicians for a given population had lower mortality rates for cancer, heart disease or stroke—three major causes of premature death—even after controlling for certain lifestyle factors (seat belt use, smoking rates) and demographic attributes (proportion of elderly people). By the 2000s researchers had linked access to such clinicians to lower rates of specific conditions, such as ruptured appendix (which requires emergency surgery) and low birth weight (which causes health problems in many infants).

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