President-Elect Barack Obama's transition webpage has a new video up featuring the nominee for Secretary of Health and Human Services, Tom Daschle, discussing health care. The transition team opened up the website last week to comments by ordinary Americans about what they would like to see in a health care reform. In the video, Daschle and an associate (Lauren Aronson) read through a few of the comments they received that they found particularly “interesting.” One of the citizen ideas that the pair latch on to is a national “health corps,” analogous to the Peace Corps. The skeletal concept is that doctors finishing their training would be encouraged to do a year or two of domestic service in communities with uneven access to health care professionals.
The attention given to this idea (one of only three mentioned, and the only concrete suggestion alongside “cost control” and “prevention”) is politically savvy: it is the kind of policy that no one is likely to disagree with, unlike the nitty-gritty details of an actual health reform. A systemic reform isn't going to happen on http://change.gov. It is going to happen in Congress (it is already happening), and there is going to be serious horse-trading. The public won't be welcome, although a President Obama may try to use the internet to rally supporters if the going gets tough.
That doesn't mean the video, or the idea of a health corps, are irrelevant. In fact, a health corps should be part of a wider strategy to deal with one of the biggest problems in the American health system: the shortage of primary care physicians. Any reform of American health care is going to rely heavily on primary care physicians to manage care and keep costs under control. Yet, as a recent White Paper from the American College of Physicians argued, primary care physicians are a dying breed. The Journal of the American Medical Association reported that, in one 2007 study, only 2 percent of fourth-year medical students intended to study general medicine. A 2008 Health Affairs study predicts a shortfall of around 40,000 primary care physicians in the United States by 2025.
Primary care physicians do not get either the respect or the salaries necessary to keep the field attractive. Previous efforts to reduce the salary gap between primary care physicians and specialists have generally failed because they involve redistributing money from powerful specialists groups to PCPs, a result that is unacceptable to specialists. Senator Max Baucus's health plan, which is currently making the rounds in Congress, would call for just this kind of redistribution, and has already been criticized on these grounds. Boosting PCP salaries without cutting specialist salaries may require some upfront costs that politicians find distasteful, particularly given the current economic climate. But if PCPs help to manage care appropriately and encourage preventive measures, the overall cost of providing care should come down, meaning that enhanced salaries are an investment that would at least partially pay for itself. It would also be easier to redistribute over time by allowing inflation to erode the salary gap rather than making a direct assault on specialists' current salaries.
But increasing the flow of doctors into primary care is not just about salaries, it is also about respect. Medicine is no different from other fields, in which specialists doing cutting edge work that is intellectually interesting tend to have higher status than those who make the more hum-drum but essential contributions upon which the poor depend. This is where the Health Corps comes in. If the President were to authorize a Health Corps that helped doctors who dedicated themselves to primary care not only receive enhanced salaries, but also enhanced status, primary care would become a more attractive field. The American College of Physicians has already called for debt reduction for doctors that go into primary care. PCPs want more autonomy and less paperwork, too. A series of presidential honors for service, starting with recognition in the Health Corps, but moving on to mid and late-career recognition (monetary and non-monetary alike) could also enhance the profile of primary care physicians. PCPs could be preferentially called on to serve on governmental panels to guide the health system, and receive Master status as teachers and mentors through a system that would parallel the academy, but be based on experience, service to the disadvantaged, and mentoring, rather than academic publications.
The program would need some fleshing out, but a Health Corps shouldn't just be a temporary foray into service for doctors who are willing to sacrifice a couple of years of high salaries. That should be part of what a Health Corps does, but it should also be a way to encourage doctors to remain in primary care, and to become experienced providers who receive salaries and status commensurate with the vital services they provide.