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History tells a tale about Magellan’s ships, that when they landed on the coast of South America, were completely ignored by the native people. Magellan and his men were astonished to see natives scarcely lifting their eyes from their busywork to look at the colossal ships in their harbor. One popular explanation is that the ships were so alien to the experience of the native people, they literally failed to ‘see’ them. Accurate or not, this explanation may be a useful metaphor for describing our current experience with a health care system. A well-functioning health care system is so alien to our experience, that we simply cannot ‘see’ it, even when it’s right before our eyes. And the ship we’re not seeing, so to speak, is Primary Care for All. Let’s rewind for a sec.
Health care reform as it is currently being carried out in this country would more accurately be called health insurance reform. We’re focusing on insurance – on a public option, on a National Exchange, etc. – and not on the delivery of actual care. Hence the title of a white paper co-authored by Michael Fine, MD and Shannon Brownlee, It’s the Delivery System—Primary Care for All, because it’s the delivery system – the system for delivering actual health care – that is what we need, and are instead ignoring while consumed in busywork with the system for providing health insurance.
There’s nothing inherently valuable about health insurance – it can’t answer phone calls or make diagnoses – it’s simply a mechanism for delivering health care, and has become a very expensive one at that. But insurance is neither sufficient nor necessary for delivering care; even with insurance, care is not guaranteed, and the seemingly wedded relationship between insurance and care is entirely contrived. We don’t necessarily need health insurance, but we do necessarily need health care. Plus, the value of health insurance is largely contained in the primary care delivered; much of the remainder is wasted. In financial terms, health insurance costs approximately $5,000-$6,000 per person per year, but the value comes almost exclusively from the $300 or less that primary care now costs most Americans. Which means, we can provide primary health care to all Americans at one twentieth of the cost it takes to provide health insurance to all Americans. And as health insurance reform now stands, even including the public option, 25 million Americans will still be uninsured by 2019, which is not to mention how many Americans will still lack affordable primary care. Meanwhile, primary care is the only medical service that’s been proven to improve the health of the population, and the only service proven to reduce the cost of health care. (How’s that for a win-win?) So if insuring all Americans is prohibitively expensive, and delivering primary care to all Americans is not only absurdly cheap in comparison, but what actually improves their health, why not just bypass insurance altogether and go straight to providing primary care for all Americans?
This is precisely what Primary Care for All seeks to do.
Proposed by family physician, community organizer, writer, and Managing Director of Health Access RI Michael Fine, MD and author of national bestseller Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer Shannon Brownlee, Primary Care for All is a way to construct a well-functioning health care system for the United States, by first providing primary care to all Americans. It proposes to bring together three systems that currently provide primary care – existing private primary care practices, Community Health Centers, and Accountable Health Care Organizations (large, vertically-integrated health systems) – to create an infrastructure that gives all Americans primary care and a primary care practice near their home. This means all Americans would have a family doctor who knows them, has known them through time, is available by phone, and can see them in an office near their neighborhood.
As described in the white paper, there are a few different ways Primary Care for All can be funded, but the basic gist is that money already sitting in insurance policies for primary care would be transferred from the hands of insurers into one big pot, and then paid to primary care practices directly. Fine and Brownlee call this pot a Primary Care Trust, and there would be one for each state. Along with being the receivers and dispensers of money, Primary Care Trusts would ensure that primary care practices are doing a good job, i.e. providing a required set of services and being open during certain hours. Additional details of Primary Care for All are further elaborated in the white paper.
The Primary Care for All model has already been endorsed by the likes of John Wennberg, MD, Barbara Starfield, MD, and Robert Warren, MD. The Family Medicine Education Consortium is seeking to raise $2,500 by November 30th and get 100,000 signatures total, in order to build the momentum necessary to write and pass legislation. When politicians and citizens alike sober up to the reality that the so-called Health Care Reform Bill only incrementally improves the insurance system, while doing nothing to deliver the care itself, there will be a prime opportunity to present them with Primary Care for All. Perhaps without health reform-related busywork on their hands, they’ll be able to look up and see the gleaming ship in the harbor. And, to mix metaphors, perhaps they’ll be ready to get on board and set sail.