PRESIDENT'S COLUMN PRIMARY HEALTH CARE Alma R. George, MD President, National Medical Association Detroit, Michigan
The public and private sectors of the United States expend vast resources on health-care services each year. However, a large percentage of this country's population lacks adequate access to health-care services. With our high rates of infant mortality, cancer, cardiovascular diseases, diabetes, and acquired immunodeficiency syndrome (AIDS), coupled with a growing number of uninsured health-care consumers, the demand for basic health-care services has increased drastically over the past decade. African Americans and other minority groups are disproportionately represented among those who are underserved, and they suffer from poor health as a result of the lack of access and availability to proper health-care services. Developing a viable primary health-care system in this country may be the first step in eradicating this health-care service crisis. Primary health care, its characteristics, and its providers will be discussed before tackling the issues of how it may better serve this country's dire health-care needs.
WHAT IS PRIMARY HEALTH CARE? At its May 1979 meeting, the World Health Assembly defined primary health care as essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them and at a cost that the community and the country can afford to maintain at every stage of their development in a spirit of self-reliance and self-determination.1 Primary health care is the basic level of health care provided and should be the first point of contact individuals and families make with their health-care system.1 Too often, the Dr George is Director, Primary Care Initiative, Surgical Services, St Joseph's Clinic, Samaritan Health Center, Detroit, Michigan. Requests for reprints should be addressed to Dr Alma R. George, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
hospital emergency room serves as the first point of contact for health-care services for many African Americans and other minorities. Such delays in treatment may lead to more expensive care or hospitalization, increasing the strain on public expenditures. The two goals of the health service system, the optimization of health and equity in distributing resources, are balanced through primary health-care programs.' Having adequate access to such programs and primary health-care providers in minority communities will help eradicate the need for hospital emergency rooms to fill this void in the health service system. There are several characteristics of primary health care that distinguishes it from secondary (consultative) and tertiary (referral) health-care services. Primary health care deals with less defined health problems, usually in a community setting such as a doctor's office, community health center, school, or home. I In a primary health-care practice, patients have access to health-care practitioners who provide health-care services over a continuous period of time for preventive, curative, and rehabilitative services to maximize the patient's overall health and well-being. ' The chief focus of primary health care is on assessing and managing the patient's symptoms, not diagnosis.' Other terms used to describe primary health care are comprehensive, available, responsible, responsive, and preventive.2 It is the area of medicine where the objective is to first prevent, then to treat, restore, preserve, or enhance the patient's physical and mental well-being. In his 1966 "Millis Report," Dr John Millis spoke of the primary care physician as one who is highly qualified in comprehensive health care, a functional specialist instead of a subject matter or technique specialist.2 The federal government lists family physicians, general internists, and general pediatricians as primary health-care providers.3 However, in some instances, gynecologists and physicians practicing emergency medicine are also listed as primary health661
PRESIDENT'S COLUMN
care providers.4 There is currently an insufficient number of health-care practitioners to meet the demand for primary health-care physicians. Because the federal government is responsible for the general welfare of the nation, it, along with the medical profession, must devise strategies to find the solutions in meeting the growing health-care needs of the entire nation and not just its privileged citizens.
THE SHORTAGE OF PRIMARY HEALTHCARE PROVIDERS While the demand for specialty medical services has increased faster than the supply of specialists since the late 1970s, new developments in health-care service indicate that there is also an increased demand for primary care practitioners. The spread of new medical conditions such as AIDS, the burden of increased morbidity of the elderly due to the aging of the baby boom generation, and the need for primary care physicians to serve as gatekeepers because of the increase in managed health-care services has placed a new and urgent demand on primary health-care physicians.1 However, with this new demand, there are not enough primary health-care practitioners to answer this call of urgency. Although evidence exists that specialty practitioners are providing some primary health-care service, specialists do not perform as well as primary care physicians in achieving the key characteristics of primary care.1 The insufficient supply of primary health-care physicians to meet this demand is one of the factors leading to the eroding access to primary health care in the United States. Some of the reasons for the shortage of primary care practitioners are the decline of medical students and physicians interested in practicing in a primary care specialty area, the financial aspects of educating physicians, the income gap between primary care practitioners and specialists, and the distribution of
physicians.
In 1970, 21.3% of medical school graduates entered primary care specialties.3 This percentage increased to 31.8% in 1980 because of the advent of family practice.3 Unfortunately, this trend is currently reversing itself The proportion of medical school graduates intending to practice in a primary care specialty has declined from 38% to 30% over the last 5 years; consequently, there has been a substantial decline in the match rate for internal medicine and family practice programs through the National Resident Matching
Program.3 As the percentage of medical school students 662
intending to practice in a primary care specialty has declined, so has the actual number of practitioners. In 1963, nearly half of the nation's physicians were practicing in a primary care specialty area; however, by 1986, only 34.3% were practicing in a primary care specialty.3 The cause for this decline seems to be a decrease in the number of physicians in general practice. To counteract this decline, the specialty of family practice was created. Unfortunately, this did not eradicate the shortage-by 1986 there were 21 864 residency-trained family physicians, still too few to compensate for the enormous decline of general practice physicians.3 The number of family and general practice physicians active in 1986 (67 687) is approximately the same number of active generalists in practice in 1967 and represents less than half the number in practice in 1949.3 The growing number of subspecialists in internal medicine and pediatrics also has contributed to the decline of primary care specialties. A total of 40.4% of internists and 11.6% of pediatricians were subspecialists in 1986, an increase over the 1981 figures.3 The financing of medical education is another factor mitigating against changing the focus of physicians' training from specialization to primary care practices. Such financing depends heavily on income derived from specialization to primary care specialties.1 Because primary care residencies generate less revenue than other specialties, teaching hospitals find it very difficult to support them. As a result, the number of first-year resident positions declined by 11% in family practice, 6.8% in internal medicine, and 4.1% in pediatrics between 1984 and 1987.3 The final factors contributing to the shortage of primary care practitioners are the income gap between primary care practitioners and specialists, and the distribution of physicians. The income gap between primary care physicians and specialists has been steadily increasing. The average income of both primary care and rural physicians did not increase as fast as the average income of all physicians between 1977 and 1986.3 With this in mind, many physicians seek to specialize. An increasing number of those in primary care exercise yet another option by working in nonpatient care activities such as administration and research, or by practicing as a full-time member of the hospital staff.3 This has led to an overall decrease in the ratio of office-based primary care physicians to the general population.3 Because rural areas rely on primary care practitioners more so than urban areas, rural areas have been JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
PRESIDENT'S COLUMN
impacted the most by the shortage of primary care practitioners. Although some newly trained family physicians are locating in rural areas, there still remains too few to make up for the number of retiring generalists, and internists and pediatricians have not followed this trend to assist in closing the gap.3 A disparity in the distribution of physicians to population in urban areas has resulted from a 45% decline in office-based primary care physicians practicing in poverty areas and a 27% decline in nonpoverty areas between 1963 and 1980.3 In comparing the trend of African-American physicians to those of the majority population, a recent survey found that a large proportion of graduates had chosen primary care specialties, practiced in the inner city, and cared for large numbers of poor, minority patients.5 The study also found that minority physicians respond to economic incentives as physicians in the majority population; therefore, it is imperative that the improvement of primary health-care service in minority communities is not placed solely on the shoulders of minority physicians, but is viewed as a responsibility of the entire medical profession.5 Just as the burden for supplying health care in the minority communities should not fall solely on AfricanAmerican physicians, neither should the use of specialists be relied on in an effort to increase the number of primary care physicians. It is up to the government, along with the medical profession, to develop effective and efficient strategies to eradicate the void in the nation's primary health-care service system.
STRATEGIES TO INCREASE THE NUMBER OF PRIMARY HEALTH-CARE PROVIDERS One of the first strategies the medical profession can use to increase the number of primary health-care providers is to improve primary health-care research. Primary health-care research can be the catalyst in guiding research in other specialty fields and can provide the answers for most of the problems facing the country's health-care system.2 The focus of primary health-care research is the individual, as opposed to an organ system or abnormal physiology.2 Other essential characteristics are its emphasis on prevention, natural history of illness, and outcomes of treatment plans.2 The government, as well as the medical profession, must acquire a better understanding of the health-care crisis to deal with it effectively, and primary health-care research can contribute greatly to that understanding. Finding solutions to meet the needs for health-care
services of specifically defined populations is another JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
task that can be solved through primary care research. The organization and management of primary care practices and programs are currently referred to as community-oriented primary care (COPC).6 The basic model of COPC consists of three elements: 1) a primary care practice or program, 2) a defined target population, and 3) a systematic process that addresses the priority health problems of the target population with both primary care and public health strategies.6 In addition, the third element in the COPC process consists of four functions: * defining and characterizing the target population, * identifying priority health and health-care problems of the population, * mounting intervention strategies or modifying practice patterns, and * monitoring the impact of interventions.6 The COPC approach to organizing, delivering, and monitoring the effects of primary care on an identified group is unique in that it is an application of the principles of epidemiology to the organization and management of primary health care for a defined population while expanding the potential of primary care to effectively meet the health care needs of the respective group.6 However, there are some obstacles to applying COPC in the mainstream of primary health care: difficulty defining a target population and accessing individuals in the target population; lack of practice resources for COPC; lack of available data on the target population; scarcity of skills, knowledge, and experience in COPC; limited tools for application of COPC in a practice setting; and the inability to obtain reimbursement for COPC processes.6 To an extent, the use of COPC methods already exist through community health centers. Community health centers were established throughout the country in the 1960s as part of the war on poverty to provide comprehensive family-oriented primary health-care services to the underserved and disadvantaged who were experiencing financial, geographic, or cultural barriers to health-care services.7 Today, the community health center functions to meet the specific needs of special segments of the population-the homeless, those infected with human immunodeficiency virus, the elderly, and substance abusers-in a cost-effective
manner.7 Several strategies have been proposed for medical education to assist in increasing the number of primary care providers. One is that medical education be funded by a tax on health-care payers and that there be a shift in positions in order for primary health-care providers to 663
PRESIDENT'S COLUMN
predominate.3 A more reasonable proposal is for federal and state policy makers to consider the nation's health needs as they appropriate funds for medical education-those wishing to pursue careers in primary health care will have access to a higher percentage of the funding.3 However, in light of the state of the national economy and the fact that physicians are well paid, professional policy makers may hesitate to support such a proposal. Finally, the government must step up its role in assisting the medical profession to increase the number of primary health-care providers. Through the National Health Service Corps (NHSC), the federal government places primary health-care providers in areas where there is a shortage of health-care services. The NHSC Revitalization Amendments of 1990 provide funding to the program through the year 2000, enabling the NHSC to initiate a campaign to recruit health-care providers to meet the needs of 35 million underserved people by providing a fivefold increase in funding for scholarships for primary care physicians, dentists, nurses, nurse practitioners, certified nurse midwives, and physician assistants, with increases in federal and state loan repayment programs.8 The goal is to improve delivery of primary care services by placing approximately 4000 primary health-care practitioners by the year 2000.8 Although federal grants have helped fund primary care residents, these appropriations have not escaped the budget cuts. Family practice residency grants were cut by $27.1 million in 1988, while grants to general internal medicine and general pediatrics declined from $19.3 million to $13.9 million during this same period, decreasing the funding for these programs by half.3 The government can also look into rearranging its Medicare payments to physicians in order that the disparity between primary care providers and specialists can be significantly narrowed. The last government action to be discussed here is the 1991 Health USA Act. The objective of the 1991 Health USA Act, introduced by Senator Bob Kerrey (D-Neb), is to reform the nation's health-care financing system while strengthening the existing delivery system.9 Through the myriad of methods presented, it is hoped that they will be used by the government and medical profession alike, both independently and collectively, to increase the number of primary health-care providers in this country.
664
CONCLUSION It is unfortunate that access to primary health care in this country is a privilege rather than a right. It is a national tragedy and disgrace that a very large segment of our society does not have access to adequate health-care services or health-care providers, and that there is not one governmental, professional, or private sector that has proposed a viable solution to this nightmare. There are no mitigating factors to weaken the financial powers that dictate the inadequate services of the health-care system in this country. Until there is a clear understanding of the primary health-care needs in this country and until the barriers to such services are removed and strategies to implement improvement are put into place, certain segments of the population that historically have been disadvantaged economically, educationally, and politically will continue to receive inadequate health-care services, and our nation's health profile will remain an embarrassment.'0 Literature Cited 1. Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992. 2. Estes E. Primary care research: where have we been? Where are we going? In: Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990:5. 3. Barnett P, Midtling J. Public policy and the supply of primary care physicians. JAMA. 1 989;262:2864-2868. 4. Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990. 5. Keith S. Role of minority providers in caring for the underserved. Journal of Health Care for the Poor and Underserved. 1990;1:92. 6. Nutting P. Community-oriented primary care: a critical area of research for primary care. In: Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990:79. 7. Community Health Centers. Fact Sheet. Bureau of Health Care Delivery & Assistance; 1992. 8. National Health Service Corps. Fact Sheet. Bureau of Health Care Delivery & Assistance; 1992. 9. Brown E. Health USA: a national health program for the United States. JAMA. 1992;267:552-558. 10. Gamliel S, Fitzhugh M, Politzer R, Stambler H. Availability of primary health care personnel: the states speak out. Arch Intern Med. 1992;152:268-273.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
The public and private sectors of the United States expend vast resources on health-care services each year. However, a large percentage of this country's population lacks adequate access to health-care services. With our high rates of infant mortality, cancer, cardiovascular diseases, diabetes, and acquired immunodeficiency syndrome (AIDS), coupled with a growing number of uninsured health-care consumers, the demand for basic health-care services has increased drastically over the past decade. African Americans and other minority groups are disproportionately represented among those who are underserved, and they suffer from poor health as a result of the lack of access and availability to proper health-care services. Developing a viable primary health-care system in this country may be the first step in eradicating this health-care service crisis. Primary health care, its characteristics, and its providers will be discussed before tackling the issues of how it may better serve this country's dire health-care needs.
WHAT IS PRIMARY HEALTH CARE? At its May 1979 meeting, the World Health Assembly defined primary health care as essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them and at a cost that the community and the country can afford to maintain at every stage of their development in a spirit of self-reliance and self-determination.1 Primary health care is the basic level of health care provided and should be the first point of contact individuals and families make with their health-care system.1 Too often, the Dr George is Director, Primary Care Initiative, Surgical Services, St Joseph's Clinic, Samaritan Health Center, Detroit, Michigan. Requests for reprints should be addressed to Dr Alma R. George, National Medical Association, 1012 10th St, NW, Washington, DC 20001. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
hospital emergency room serves as the first point of contact for health-care services for many African Americans and other minorities. Such delays in treatment may lead to more expensive care or hospitalization, increasing the strain on public expenditures. The two goals of the health service system, the optimization of health and equity in distributing resources, are balanced through primary health-care programs.' Having adequate access to such programs and primary health-care providers in minority communities will help eradicate the need for hospital emergency rooms to fill this void in the health service system. There are several characteristics of primary health care that distinguishes it from secondary (consultative) and tertiary (referral) health-care services. Primary health care deals with less defined health problems, usually in a community setting such as a doctor's office, community health center, school, or home. I In a primary health-care practice, patients have access to health-care practitioners who provide health-care services over a continuous period of time for preventive, curative, and rehabilitative services to maximize the patient's overall health and well-being. ' The chief focus of primary health care is on assessing and managing the patient's symptoms, not diagnosis.' Other terms used to describe primary health care are comprehensive, available, responsible, responsive, and preventive.2 It is the area of medicine where the objective is to first prevent, then to treat, restore, preserve, or enhance the patient's physical and mental well-being. In his 1966 "Millis Report," Dr John Millis spoke of the primary care physician as one who is highly qualified in comprehensive health care, a functional specialist instead of a subject matter or technique specialist.2 The federal government lists family physicians, general internists, and general pediatricians as primary health-care providers.3 However, in some instances, gynecologists and physicians practicing emergency medicine are also listed as primary health661
PRESIDENT'S COLUMN
care providers.4 There is currently an insufficient number of health-care practitioners to meet the demand for primary health-care physicians. Because the federal government is responsible for the general welfare of the nation, it, along with the medical profession, must devise strategies to find the solutions in meeting the growing health-care needs of the entire nation and not just its privileged citizens.
THE SHORTAGE OF PRIMARY HEALTHCARE PROVIDERS While the demand for specialty medical services has increased faster than the supply of specialists since the late 1970s, new developments in health-care service indicate that there is also an increased demand for primary care practitioners. The spread of new medical conditions such as AIDS, the burden of increased morbidity of the elderly due to the aging of the baby boom generation, and the need for primary care physicians to serve as gatekeepers because of the increase in managed health-care services has placed a new and urgent demand on primary health-care physicians.1 However, with this new demand, there are not enough primary health-care practitioners to answer this call of urgency. Although evidence exists that specialty practitioners are providing some primary health-care service, specialists do not perform as well as primary care physicians in achieving the key characteristics of primary care.1 The insufficient supply of primary health-care physicians to meet this demand is one of the factors leading to the eroding access to primary health care in the United States. Some of the reasons for the shortage of primary care practitioners are the decline of medical students and physicians interested in practicing in a primary care specialty area, the financial aspects of educating physicians, the income gap between primary care practitioners and specialists, and the distribution of
physicians.
In 1970, 21.3% of medical school graduates entered primary care specialties.3 This percentage increased to 31.8% in 1980 because of the advent of family practice.3 Unfortunately, this trend is currently reversing itself The proportion of medical school graduates intending to practice in a primary care specialty has declined from 38% to 30% over the last 5 years; consequently, there has been a substantial decline in the match rate for internal medicine and family practice programs through the National Resident Matching
Program.3 As the percentage of medical school students 662
intending to practice in a primary care specialty has declined, so has the actual number of practitioners. In 1963, nearly half of the nation's physicians were practicing in a primary care specialty area; however, by 1986, only 34.3% were practicing in a primary care specialty.3 The cause for this decline seems to be a decrease in the number of physicians in general practice. To counteract this decline, the specialty of family practice was created. Unfortunately, this did not eradicate the shortage-by 1986 there were 21 864 residency-trained family physicians, still too few to compensate for the enormous decline of general practice physicians.3 The number of family and general practice physicians active in 1986 (67 687) is approximately the same number of active generalists in practice in 1967 and represents less than half the number in practice in 1949.3 The growing number of subspecialists in internal medicine and pediatrics also has contributed to the decline of primary care specialties. A total of 40.4% of internists and 11.6% of pediatricians were subspecialists in 1986, an increase over the 1981 figures.3 The financing of medical education is another factor mitigating against changing the focus of physicians' training from specialization to primary care practices. Such financing depends heavily on income derived from specialization to primary care specialties.1 Because primary care residencies generate less revenue than other specialties, teaching hospitals find it very difficult to support them. As a result, the number of first-year resident positions declined by 11% in family practice, 6.8% in internal medicine, and 4.1% in pediatrics between 1984 and 1987.3 The final factors contributing to the shortage of primary care practitioners are the income gap between primary care practitioners and specialists, and the distribution of physicians. The income gap between primary care physicians and specialists has been steadily increasing. The average income of both primary care and rural physicians did not increase as fast as the average income of all physicians between 1977 and 1986.3 With this in mind, many physicians seek to specialize. An increasing number of those in primary care exercise yet another option by working in nonpatient care activities such as administration and research, or by practicing as a full-time member of the hospital staff.3 This has led to an overall decrease in the ratio of office-based primary care physicians to the general population.3 Because rural areas rely on primary care practitioners more so than urban areas, rural areas have been JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
PRESIDENT'S COLUMN
impacted the most by the shortage of primary care practitioners. Although some newly trained family physicians are locating in rural areas, there still remains too few to make up for the number of retiring generalists, and internists and pediatricians have not followed this trend to assist in closing the gap.3 A disparity in the distribution of physicians to population in urban areas has resulted from a 45% decline in office-based primary care physicians practicing in poverty areas and a 27% decline in nonpoverty areas between 1963 and 1980.3 In comparing the trend of African-American physicians to those of the majority population, a recent survey found that a large proportion of graduates had chosen primary care specialties, practiced in the inner city, and cared for large numbers of poor, minority patients.5 The study also found that minority physicians respond to economic incentives as physicians in the majority population; therefore, it is imperative that the improvement of primary health-care service in minority communities is not placed solely on the shoulders of minority physicians, but is viewed as a responsibility of the entire medical profession.5 Just as the burden for supplying health care in the minority communities should not fall solely on AfricanAmerican physicians, neither should the use of specialists be relied on in an effort to increase the number of primary care physicians. It is up to the government, along with the medical profession, to develop effective and efficient strategies to eradicate the void in the nation's primary health-care service system.
STRATEGIES TO INCREASE THE NUMBER OF PRIMARY HEALTH-CARE PROVIDERS One of the first strategies the medical profession can use to increase the number of primary health-care providers is to improve primary health-care research. Primary health-care research can be the catalyst in guiding research in other specialty fields and can provide the answers for most of the problems facing the country's health-care system.2 The focus of primary health-care research is the individual, as opposed to an organ system or abnormal physiology.2 Other essential characteristics are its emphasis on prevention, natural history of illness, and outcomes of treatment plans.2 The government, as well as the medical profession, must acquire a better understanding of the health-care crisis to deal with it effectively, and primary health-care research can contribute greatly to that understanding. Finding solutions to meet the needs for health-care
services of specifically defined populations is another JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
task that can be solved through primary care research. The organization and management of primary care practices and programs are currently referred to as community-oriented primary care (COPC).6 The basic model of COPC consists of three elements: 1) a primary care practice or program, 2) a defined target population, and 3) a systematic process that addresses the priority health problems of the target population with both primary care and public health strategies.6 In addition, the third element in the COPC process consists of four functions: * defining and characterizing the target population, * identifying priority health and health-care problems of the population, * mounting intervention strategies or modifying practice patterns, and * monitoring the impact of interventions.6 The COPC approach to organizing, delivering, and monitoring the effects of primary care on an identified group is unique in that it is an application of the principles of epidemiology to the organization and management of primary health care for a defined population while expanding the potential of primary care to effectively meet the health care needs of the respective group.6 However, there are some obstacles to applying COPC in the mainstream of primary health care: difficulty defining a target population and accessing individuals in the target population; lack of practice resources for COPC; lack of available data on the target population; scarcity of skills, knowledge, and experience in COPC; limited tools for application of COPC in a practice setting; and the inability to obtain reimbursement for COPC processes.6 To an extent, the use of COPC methods already exist through community health centers. Community health centers were established throughout the country in the 1960s as part of the war on poverty to provide comprehensive family-oriented primary health-care services to the underserved and disadvantaged who were experiencing financial, geographic, or cultural barriers to health-care services.7 Today, the community health center functions to meet the specific needs of special segments of the population-the homeless, those infected with human immunodeficiency virus, the elderly, and substance abusers-in a cost-effective
manner.7 Several strategies have been proposed for medical education to assist in increasing the number of primary care providers. One is that medical education be funded by a tax on health-care payers and that there be a shift in positions in order for primary health-care providers to 663
PRESIDENT'S COLUMN
predominate.3 A more reasonable proposal is for federal and state policy makers to consider the nation's health needs as they appropriate funds for medical education-those wishing to pursue careers in primary health care will have access to a higher percentage of the funding.3 However, in light of the state of the national economy and the fact that physicians are well paid, professional policy makers may hesitate to support such a proposal. Finally, the government must step up its role in assisting the medical profession to increase the number of primary health-care providers. Through the National Health Service Corps (NHSC), the federal government places primary health-care providers in areas where there is a shortage of health-care services. The NHSC Revitalization Amendments of 1990 provide funding to the program through the year 2000, enabling the NHSC to initiate a campaign to recruit health-care providers to meet the needs of 35 million underserved people by providing a fivefold increase in funding for scholarships for primary care physicians, dentists, nurses, nurse practitioners, certified nurse midwives, and physician assistants, with increases in federal and state loan repayment programs.8 The goal is to improve delivery of primary care services by placing approximately 4000 primary health-care practitioners by the year 2000.8 Although federal grants have helped fund primary care residents, these appropriations have not escaped the budget cuts. Family practice residency grants were cut by $27.1 million in 1988, while grants to general internal medicine and general pediatrics declined from $19.3 million to $13.9 million during this same period, decreasing the funding for these programs by half.3 The government can also look into rearranging its Medicare payments to physicians in order that the disparity between primary care providers and specialists can be significantly narrowed. The last government action to be discussed here is the 1991 Health USA Act. The objective of the 1991 Health USA Act, introduced by Senator Bob Kerrey (D-Neb), is to reform the nation's health-care financing system while strengthening the existing delivery system.9 Through the myriad of methods presented, it is hoped that they will be used by the government and medical profession alike, both independently and collectively, to increase the number of primary health-care providers in this country.
664
CONCLUSION It is unfortunate that access to primary health care in this country is a privilege rather than a right. It is a national tragedy and disgrace that a very large segment of our society does not have access to adequate health-care services or health-care providers, and that there is not one governmental, professional, or private sector that has proposed a viable solution to this nightmare. There are no mitigating factors to weaken the financial powers that dictate the inadequate services of the health-care system in this country. Until there is a clear understanding of the primary health-care needs in this country and until the barriers to such services are removed and strategies to implement improvement are put into place, certain segments of the population that historically have been disadvantaged economically, educationally, and politically will continue to receive inadequate health-care services, and our nation's health profile will remain an embarrassment.'0 Literature Cited 1. Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press; 1992. 2. Estes E. Primary care research: where have we been? Where are we going? In: Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990:5. 3. Barnett P, Midtling J. Public policy and the supply of primary care physicians. JAMA. 1 989;262:2864-2868. 4. Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990. 5. Keith S. Role of minority providers in caring for the underserved. Journal of Health Care for the Poor and Underserved. 1990;1:92. 6. Nutting P. Community-oriented primary care: a critical area of research for primary care. In: Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the '90s, AHCPR Conference Proceedings. Rockville, Md: Agency for Health Care Policy and Research; 1990:79. 7. Community Health Centers. Fact Sheet. Bureau of Health Care Delivery & Assistance; 1992. 8. National Health Service Corps. Fact Sheet. Bureau of Health Care Delivery & Assistance; 1992. 9. Brown E. Health USA: a national health program for the United States. JAMA. 1992;267:552-558. 10. Gamliel S, Fitzhugh M, Politzer R, Stambler H. Availability of primary health care personnel: the states speak out. Arch Intern Med. 1992;152:268-273.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 8
