Primary Care, Psychiatry And Public Health: What Do They Have In Common And Why Does It Matter?

Why should these three fields in health care have anything in common? They seem so disparate, and if they do have some things in common, why and how should that make a difference? This paper explores these questions and makes the case that the answers are essential to reforming the U. S. health care non-system in the best interests of patients, families and populations. Here we have two goals: (1) to outline what these three fields have in common, including widespread inequities and unacceptable quality of care, and why it matters; and (2) to describe how bringing a system of universal access through Medicare for All can address today’s system problems.

What Do These Three Fields Have in Common?

1. Under-reimbursed, underfunded, and/or neglected

Primary Care

• Because of low Medicaid reimbursement (61 percent of what insurers

pay for private coverage), only two-thirds of U. S. primary care

physicians will see new patients on Medicaid. 1

• Although primary care and public health share common and synergistic

goals, they have both been chronically underfunded despite the

landmark 1966 report, “Health is a Community Affair”, updated in 2012.2

Psychiatry

• “Inadequate reimbursement for time-consuming “talk therapy” without

compensatory procedural reimbursement.

• Lack of parity of coverage for physical and mental illness.

• Rapid decline of psychotherapy and shift toward drug therapy and

“med checks” practice.

• Draconian cuts in state budgets for mental health and mental illness care.” 3

Public Health

An investigation by Kaiser Health News and the Associated Press reported these striking findings in July, 2020:

• Since 2010, spending on state health departments has dropped by 16 %

per capita, and in local health departments by 18%, in 2019 dollars after

adjusting for inflation.

• Some public health workers earn so little that they qualify for

government assistance. During the pandemic, many found themselves

disrespected, ignored or even vilified. 4

• The Trump administration denigrated the importance of testing and face masks during the pandemic while also cutting funding and firing key professionals at the CDC.”5

Dr. Karen DeSalvo, as acting assistant secretary of the Department of Health and Human Services, identified in 2015 the disconnect in the funding of public health this way:

Public health infrastructure has a history of being there when necessary, but on the other hand increasingly being marginalized and underfunded year after year. We are starving our infrastructure. Even though 80 percent of people’s health is influenced by what happens outside of doctors’ offices and hospitals, about 97 percent of funding goes to pay for medical services. 6

2. Workforce shortages

Primary Care

• As medical school graduates increasingly select the more highly reimbursed specialties, the Association of American Medical Colleges (AAMC) predicts a shortage of primary care physicians of between 21,000 and 55,200 physicians by 2032. 7

• The U. S. lacks a national physician workforce plan, with serious shortages in primary care, psychiatry and less procedurally-oriented specialties.

• Primary care physicians in smaller group practices, already in short supply, faced such a large drop in patient volume during the pandemic that they thought that they may be forced to close their practices. 8

• By November 2020, 16,000 primary care physicians had closed their practices due to the stress of the pandemic. 9

Psychiatry

According to the AAMC,

• The U. S. has an escalating shortage of psychiatrists, more than in any other specialty, with a projected shortage in 2025 up to 15,600 psychiatrists;

• This shortage is occurring as the demand for mental health care keeps increasing; and

• More than one half of U. S. counties have no psychiatrists. 10

Public Health

• At least 38,000 public health jobs have disappeared since the 2008 recession; 75 percent of U. S. counties had no epidemiologist to track COVID-19 when the pandemic hit.11

• An ongoing investigation by the Associated Press and Kaiser Health News found that, six months into the pandemic, more than 181 state and public health leaders in 38 states had resigned, retired or been fired as a result of politicization of public health measures by far-right activists, conservative groups and anti-vaccination extremists. 12

3. Inadequate access to care

Primary Care

A May 2020 study found that more than one-half of American women reported that they or a family member had skipped or delayed medical care due to the pandemic. 13

Unaffordable care, especially for the 30 million uninsured and 87 million underinsured Americans. 14

• Increased cost sharing through deductibles, co-payments, co-insurance and out-of-pocket costs does not control costs or spending and leads to underuse of needed care. 15

• A 2020 national study found that 56 percent of U. S. adults were either somewhat or very concerned that a health situation in their household could lead to medical bankruptcy or debt, with one-third foregoing healthcare because they couldn’t afford it. 16

• Decimation of the safety net, especially in lower-income urban settings and rural areas.

Psychiatry

• Almost one in five Americans have a mental health condition, according to the Substance Abuse and Mental Health Services Administration.

• A recent report from the Government Accountability Office found that the numbers of Americans with anxiety or depression symptoms increased by fourfold during the COVID pandemic, compared to 2019. 17

• 111 million Americans are living in mental health professional shortage areas. 18

• Access is further constrained by restrictive barriers and limits to care by private insurers, such as premature discharge without adequate outpatient care. 19

Public Health

The overall goal of public health is to “secure health and promote wellness for both individuals and communities, by addressing societal, environmental, and individual determinants of health.” 20 This is all about health promotion, prevention of disease and accidents, and bad health outcomes through such means as vaccination, control of infectious diseases, and safer workplaces. Its effectiveness, however, is limited by chronic underfunding. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health. 21

4. Widespread disparities and inequities

• Rising inequality within the U. S. population has led to a growing gulf between the haves and have nots, with 43 million Americans out of 330 million living in poverty. 22

Women’s health care, mental health, and rural health care have been disadvantaged for many years.

• The richest 1 percent of Americans now hold more of our nation’s wealth than the bottom 90 percent. 23

Although being only 12.5 percent of the U. S. population, African-Americans have accounted for 23 percent of all COVID-19 deaths. 24

5. Unacceptable quality and outcomes of care

• The primary care shortage contributes to lower quality of care, since it has been shown that every increase of 10 primary care physicians per 100,000 population has been associated with reductions in mortality of 0.9% to 1.4% from cardiovascular, cancer, and respiratory diseases. 25

• Thousands of patients in South Dakota with severe diabetes, blindness or mental illness end up being warehoused unnecessarily in sterile, highly restrictive group homes, a violation of their civil liberties according to the Justice Department. 26

• Porous mental health system, with many patients criminalized in jails, often without receiving treatment.

• With curative drugs for hepatitis C costing more than $90,000 for a course of treatment, many prisons are rationing care to only the sickest of infected inmates. 27

• According to the Commonwealth Fund, the U. S. lags behind other advanced countries in terms of mortality amenable to health care. 28

Why does this matter?

Collectively, these data points in three major foundational fields of our health care system tell a story that should draw us up short. Because of chronic underfunding and lack of serious health planning, all three fields are falling far short of meeting national needs and the public interest. It is beyond time to take stock of these changes and expedite reforms for the common good, not for the interests of corporate stakeholders and investors in our medical-industrial complex.

6. What Should Be Done?

We need a system of universal access for these reasons:

• A 2019 study predicted that more than 50 million Americans will die earlier over the next generation unless the U. S. moves to a system of universal coverage. 29

• It levels the playing field for all Americans in terms of ensuring access to needed care.

• The poverty level can be reduced by more than 20 percent by eliminating cost-sharing, self-payments and other out-of-pocket costs for health care at the point of service. 30

• The 30-plus million Americans testing positive for COVID will receive necessary care.

There are three major reform alternatives before the Biden administration and Congress: (1) building on the ACA; (2) some variant of a public option; and (3) Medicare for All. The first two, however, would never achieve universal coverage, would leave a profiteering private health insurance industry in place, and would fail to achieve cost containment.

Medicare for All

This is the only reform alternative that can get the U. S. out of its dysfunctional status quo, with its inadequate access, unaffordable prices and costs, unacceptable quality, disparities and inequities. All of these have been present for many years, but are exacerbated and unmasked by the COVID-19 pandemic.

There are two bills in Congress now that would bring forward single-payer Medicare for All, a new program of national health insurance—H. R. 1976 in the House with enabling legislation in the Senate. When lead co-sponsor Rep. Pramila Jayapal (D-WA) introduced the House bill, she said:

While this devastating pandemic is shining a bright light on our broken, for profit health care system, we were already leaving nearly half of adults under age 65 uninsured or underinsured before COVID-19 hit. And we were cruelly doing so while paying more per capita for health care than any other country in the world. 31

Medicare for All offers these advantages that are not included in the previous two options:

• Coverage for all medically necessary health care for U. S. residents, together with expanded funding for primary care, mental health and public health.

• Comprehensive benefits based on medical need, not ability to pay, with full choice of physicians, other health care professionals, and hospitals anywhere in the country.

• Elimination of cost sharing at the point of care, such as co-pays, deductibles, and the current need for pre-authorization through private insurers.

• Helps the labor market and economy by allowing employers to redirect money they have been spending on health care to their employees’ wages. 32

• Administrative simplification with efficiencies and cost containment through large-scale cost controls, including negotiated fee schedules, global budgeting of hospitals and other facilities, and bulk purchasing of drugs and medical devices.

• Establishes an Office of Health Equity to monitor and eliminate health disparities and promote primary care.

• Protects the national health program by preventing any future administration form reducing or eliminating existing benefits.

• Expands support for older and disabled Americans by expanding eligibility for long-term care and services.

• Shares risk for the costs of illness and accidents across our entire population of 330 million Americans. 33

Cost savings by shifting over to a more efficient, not-for-profit public financing system will enable universal coverage, as documented by Gerald Friedman, Professor of Economics at the University of Massachusetts Amherst, who has studied the costs of Medicare for All for more than ten years. He has found that we would have saved more than $1 trillion in 2019 had such a single payer system been in place that year. These savings can be achieved for three areas of health care spending—provider administration (the billing process), insurance administration (interaction with multi-payer private insurers), and reduction to Medicare negotiated payments to hospitals, drug companies and medical equipment manufacturers (through bulk purchasing and negotiated prices). 34

Other studies have come to similar conclusions about cost savings.

A Yale University study found that Medicare for All would avoid losing 68,000 lives a year while gaining more than $450 billion in savings. 35 More recently, the Congressional Budget Office (CBO) projects that Medicare for All will save $650 billion in 2030. 36

National polls for many years have shown majority support for Medicare for All. As the battle over health care reform now shifts to the 2022 elections, control of the Senate will again be up for grabs, with 34 seats up for election—20 held by Republicans and 14 by Democrats.

Amidst this high-stakes battle for the future of U. S. health care in our highly polarized society, this insight by Drs. Peter Arno and Phil Caper, based on their long experience with health policy, is spot on:

The real struggle for a universal single payer system in the U. S. is not technical or economic but almost entirely political. Retaining anything resembling the status quo is the least disruptive, and therefore politically easier route. Unfortunately, it is also the least effective route to attack the underlying pathology of the American health care system—corporatism run amok. Adopting the easiest route will do little more than kick the can down the road and will require repeatedly revisiting the deficiencies in our health care system until we get it right. 37

References.

1/ Two-thirds of primary care physicians accepted new Medicaid patients in 2011-2012. A baseline to measure future acceptance rates. Health Affairs 32 (7): 1183-1187, 2013.

2/ Westfall, JM, Liaw, W, Griswold, K et al. Uniting public health and primary care for healthy communities in the Covid-19 era and beyond. Am Board Fam Med 34: S203-209, 2021.

3/Geyman, JP. Challenges to the future of psychiatry: Parallels with primary care. Psychiatric Annals 44 (1): 61-64, 2014.

4/  Press release. Six takeaways of the KHN-AP investigation into the erosion of public health. Kaiser Health News/Associated Press, July 1, 2020.

5/ Contrera, J. Still too few N95s where the need is greatest. The Washington Post, September 23, 2020: A 1.

6/ DeSalvo, K. As quoted by O’Donnell, J, Unger, L. Public health gets least money, but does most. USA Today, December 8, 2015.

7/ Knight, V. American medical students less likely to choose to become primary care doctors. Kaiser Health News, July 3, 2019.

8/ Slavitt, A, Mostashari, F. COVID-19 is battering independent physician practices. STAT, May 28, 2020.

9/ Ungar, L. Thousands of doctors’ offices buckle under financial stress of COVID. Kaiser Health News, November 30, 2020.

10/ Weiner, S. Addressing the escalating psychiatrist shortage. AAMC, February 12, 2018.

11/ Rosenthal, E. How the U. S. invested in the war on terrorism at the cost of public health. Op-Ed. Los Angeles Times, March 28, 2021.

12/ Barry-Jester, AM, Recht, H, Smith, MR et al. Pandemic backlash jeopardizes public health powers, leaders. Kaiser Health News, December 15, 2020.

13/ Weigel, G, Salganicoff, A. Potential effects of delaying “non-essential” reproductive health care. Issue Brief. Kaiser Family Foundation, June 24, 2020.

14/ Collins, SR, Bhupal, HK, Doty, MM. Health insurance coverage eight years after the ACA. The Commonwealth Fund, February 7, 2019.

15/ Davis, K. Half of insured adults with high-deductible health plans experience medical bill or debt problems. New York. The Commonwealth Fund, January 27, 2005.

16/ Grunebaum, D. Majority of U. S. adults concerned about medical bankruptcy, debt. HealthCareInsider, October 29, 2020.

17/ Huetteman, E. Mental health services wane as insurers appear to skirt parity rules during the pandemic. Kaiser Health News, April 30, 2021.

18/ Ibid # 10.

19/ Munoz, R. How health care insurers avoid treating mental illness. San Diego Union Tribune, May 22, 2020.

20/ The Institute for the Future: Health and Health Care 2010: The Forecast, the Challenge. San Francisco, CA. Jossey-Bass, 2000.

21/ Ibid # 4.

22/ Powers, N. Fear of a black planet: Under the Republican push for welfare cuts, racism boils. Truthout, January 21, 2018.

23/ Hightower, J. It’s time for a (teeny) tax on wealth. The Hightower Lowdown 21 (8): 1-2, September, 2019.

24/ Morath, E, Omeokwe, A. virus obliterates black job market. Wall Street Journal, June 10, 2020: A1.

25/ Basu, S, Berkowitz, SA, Phillips, RL et al. Association of primary care physician supply with population mortality in the United States, 2005-2015. JAMA InternMed online, February 18, 2019.

26/ Apuzzo, M. South Dakota wrongly puts thousands in nursing homes, government says. New York Times, May 2, 2016.

27/ Loftus, P, Fields, G. Costly drugs for prisoners with hepatitis C on public budgets. Wall Street Journal, September 13, 2016: A 1.

28/ Blumenthal, D, Collins, SR, Radley, DC. 2017 Commonwealth Fund International Health Policy Survey of Older Adults in 11 countries. New York. The Commonwealth Fund, December 1, 2017.

29/ Escobar, KM, Murariu, D, Munro, S. Care of acute conditions and chronic conditions in Canada and the United States: Rapid systemic review and meta-analysis. J Public Health Research, March 11, 2019.

30/ Bruenig, M. Medicare for All would cut poverty by over 20 percent. People’s Policy Project, September 12, 2019.

31/ Jayapal, P. As quoted by Wilkins, B. ‘Everybody in, nobody out’: Jayapal, Dingell introduce Medicare for All Act with 112 co-sponsors. Common Dreams, March 17, 2021.

32/ Bivens, J. Fundamental reform like ‘Medicare for All’ would help the labor market. Economic Policy Institute, March 5, 2020.

33/ Rogers, S. Introducing the new (and improved) Medicare for All Act of 2021. Press release. Physicians for a National Health Program. Chicago, IL, March 17, 2021.

34/ Friedman, E. The Case for Medicare for All. Medford, MA. Polity Press, 2020, pp 62-63.

35/ Galvani, AP, Parpia, AS, Foster, EM et al. Improving the prognosis of health care in the USA. Lancet 395 (10223), February, 2020.

36/ Bruenig, M. A new Congressional Budget Office study shows that Medicare for All would save hundreds of billions of dollars a year. Jacobin, December 19, 2020.

37/ Arno, P, Caper, P. Medicare for All: The social transformation of U. S. health care. Health Affairs, March 25, 2020.

 

 

John Geyman, M.D. is professor emeritus of Family Medicine at the University of Washington School of Medicine in Seattle, where he served as Chairman of the Department of Family Medicine from 1976 to 1990. His most recent publications are Struggling and Dying under TrumpCare: How We Can Fix this Fiasco (2019) and a pamphlet, Common Sense: The Case For and Against Medicare for All, Leading Issue in the 2020 Elections (2019).

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