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).[break]
A study of more than 9,500 people with either high blood pressure or high cholesterol, which was published in the American Heart Journal this past July, sheds a little more light on why this relationship works so well. It found that having a usual source of care—a primary care provider or clinic—significantly decreased a person’s risk of going untreated for high blood pressure or high cholesterol whether or not the individual had insurance. This finding suggests that health reform has to do more than provide affordable health coverage for all who need it. It must also ensure access to a primary care provider.
Primary care has delivered some of its greatest gains in the African-American population. One study from 2005 showed that access reduced deaths in that group four times more than in whites—even after controlling for education and income. Part of the difference probably has to do with the slightly higher rates of hypertension among African-Americans. Treating high blood pressure is a proved way of preventing heart attack, stroke and kidney failure. Part of the difference also probably has to do with regular screening for cancers—such as colon and cervical—that are readily treatable if caught early. “In the cancer realm, a lot of the difference [between racial/ethnic groups] is lack of insurance and lack of a usual source of medical care,” says Ann S. O’Malley, a primary care physician who is a senior researcher at the Center for Studying Health System Change in Washington, D.C. Both lines of evidence strongly suggest that making primary care more broadly available could go a long way toward decreasing health disparities among whites, blacks and other racial/ethnic groups.
Among wealthier people, a big, perhaps surprising benefit of primary care is that it keeps patients from going too often to a specialist, where they can be overtreated or misdiagnosed. “Most people do not realize the dangers of too much specialty care,” says Barbara Starfield, a health systems researcher at the Johns Hopkins Bloomberg School of Public Health. She points to research showing that primary care physicians are better all-around diagnosticians than specialists and achieve better overall health outcomes for their patients. Unnecessary treatment turns out to be a bigger problem than most people in the medical field—including specialists—care to admit. Every test, every diagnostic procedure, every surgery has its own complication rates. For example, undergoing cardiac catheterization to see if the arteries in your heart are blocked slightly increases the risk of fatal internal bleeding—which is why you have to lie so still after the procedure.
Primary care is not a panacea, of course. Sometimes you really do need a brain surgeon to save your life. But more and more high-performing health care networks are noticing the benefits and reorganizing care delivery, as a report by the Josiah Macy Foundation concluded in the spring. After North Carolina restructured some of its pediatric Medicaid programs in the late 1990s to emphasize primary care—providing more evening and weekend appointments and paying for more follow-up visits—hospitalizations for asthma dropped by 40 percent. In 2007 the Group Health Cooperative in Washington State determined that patient satisfaction was up, visits to the emergency room were down, and costs were lowered just one year after it started providing more primary care services.
Of course, for the nation to reap the advantages of primary care, it must have enough practitioners. The health reform laws of 2010 increased the payment for some primary care services by 10 percent, but it did not go far enough to address the growing shortage of providers, Starfield and O’Malley say. Physicians are retiring from or leaving primary care in droves because it does not pay as well as specialty care. Advanced practice nurses and other health care workers who could meet more of the demand are hamstrung by outdated state regulations. “I am a primary care–trained physician, and I can’t find a primary care provider for myself,” O’Malley says. Access is likely to get tighter. The Congressional Budget Office estimates that an additional 32 million previously uninsured people will have health coverage as a result of the health laws of 2010. If health care reform is going to succeed, they—like the rest of us—will need to find a primary care provider.