Primary Care Physician Shortage Creates Medically Disenfranchised Population

The shortage of primary care physicians has left millions of Americans without primary health care services, creating a population of medically disenfranchised individuals who lack access to medical homes, says a study conducted jointly by the National Association of Community Health Centers, or NACHC, and the AAFP's Robert Graham Center.

Nearly one in five Americans -- 56 million individuals -- are medically disenfranchised, meaning they have inadequate or no access to primary care physicians because of the shortage of such physicians, says the report, "Access Denied: A Look at America's Disenfranchised." (PDF file: 42 pages / 1.2 MB. More about PDFs.)

The medically disenfranchised come from all income levels, racial backgrounds and ethnic groups, and it is important to note that most of these individuals have health insurance. However, they all lack one vital health care component -- a medical home to address basic health care needs.

"Having insurance coverage without a source of care is as worthless as having currency without a marketplace," said Joseph Feaster Jr., speaker of the house of NACHC and one of five speakers who addressed a congressional briefing on the Access Denied report here March 16.

Feaster defined a medical home as a "patient-centered, regular and continuous source of primary care."

Feaster added, "If you have a health care home -- whether you have insurance or not -- you are more likely to have better and lower health care costs. You also are less likely to visit a hospital emergency room or get admitted to a hospital."

He referred to the medically disenfranchised as "health care have-nots who are left to languish in a health care system that has turned its back on preventive medicine."

"The toll of unmet health care needs among these health care have-nots is incalculable, and the tragic outcomes they experience are appalling," said Feaster.

He cited the following statistics from the report.

The congressional briefing used the experiences of the five featured panelists to dramatize the plight of the medically disenfranchised and to emphasize the importance of community health centers in providing care to the medically underserved. In the process, the briefing put a human face on the facts and figures cited in the report.

Panelist Gail Baldwin, M.D., medical director of the Lake Superior Community Health Center in Duluth, Minn., and an AAFP member, told the story of a 43-year-old woman who came into the health center suffering from a cold and was subsequently diagnosed with breast cancer. It was the woman's first contact with a health care provider in 11 years, and the center's diagnosis saved the woman's life, making it possible for her to return to her job and to continue taking care of her 11-year-old son, Baldwin said.

"Most of our patients are living in poverty, and it does not take much to get there," noted Baldwin.

In many instances, community health center patients earn about $15,000 a year, she said, and even though they may have insurance through their jobs, their insurance deductibles may stand at $5,000. That's a deductible they cannot meet, according to Baldwin, effectively precluding health care access.

Community health centers operate on a sliding scale basis -- people pay what they can afford, making the centers a lifeline for the medically disenfranchised, Baldwin said.

Panelist Bill Underwood, president of the board of directors for Clinica Sierra Vista, a community health center in Bakersfield, Calif., was a successful electronics expert for the oil industry in 1989 when he suffered two heart attacks that left him financially destitute. Underwood, who was uninsured at the time, became bankrupt and then homeless, eventually ending up at a homeless clinic run by Clinica Sierra Vista.

With the clinic's help, Underwood started receiving social security benefits from the federal government and was able to start seeing specialists for his heart condition.

"I have been diabetic since I was 7 years old," Underwood explained. "At the time I had the heart attacks, I had no primary physician. Clinica stepped in and provided all of these services. I wouldn't be here today without Clinica."

The panelists addressed the shortage of primary care physicians during the question-and-answer segment of the briefing, saying the shortage is due, in part, to the decrease in the number of medical school graduates who choose primary care as a profession.

Baldwin talked about the "great expense" of medical school and reminded the audience that primary care specialties are among the "lowest paid," which makes it difficult to pay back student loans.

Primary care involves a "coordinated approach to caring for people," Baldwin said. Yet, public and private payment rates for primary care services lag behind those paid for services provided by many other specialties, discouraging physicians from pursuing a career in family medicine, she said.

The Access Denied report notes that "the number of primary care physicians per capita has changed very little, while the number of specialists has been rapidly growing. … Primary care specialties have lost their appeal to U.S. medical school graduates, and specific primary care specialties are seeing young physicians look to more lucrative sub-specialization."

The report also made the following points.