An open letter to Barack Obama and John McCain

Dear Senators McCain and Obama:

I am a Nashua, New Hampshire primary care physician and as an independent, swing voter, will be important to your Presidential fortunes in this battleground state.

As a primary care doctor, it comes as no surprise that I have focused on your proposals to reform our healthcare system. I applaud both of your efforts, and they could not be more different. The election will truly be a referendum on whether the country will endorse the left’s focus on universal coverage, or the market-based solutions of the right.

The United States boasts the world’s most expensive health care system, and has close to 50 million citizens without health insurance. After scouring your websites and listening to your rhetoric, it is discouraging that you propose very few solutions that address the root of today’s healthcare problems: the primary care physician shortage.

Senator Obama, your plan is strikingly similar to the reform underway in Massachusetts. You keep the current system intact, and strongly encourage (versus mandating) citizens to obtain health insurance from a private or public insurer.

However, you assume that there will be enough primary care doctors to care for this sudden influx of newly insured patients. As Massachusetts is finding out, that is far from the case. Dr. Bruce Auerbach, president-elect of the Massachusetts Medical Society, sums up the problem:

“It is a fundamental truth “” which we are learning the hard way in Massachusetts “” that comprehensive health care reform cannot work without appropriate access to primary care physicians and providers.”

And this is a state that ranks far above average in the per capita supply of primary care doctors.

Newly insured patients who cannot access timely primary care will flood the already crowded emergency rooms, further driving up the cost of care.

Implementing your plan without a solid primary care foundation will doom your proposal to failure. Universal coverage is useless without appropriate access to care.

Senator McCain, first let me say that your absence in July’s vote on the Medicare bill to repeal physician payment cuts was disappointing. Choosing not to support physicians will certainly linger in my mind on November 4th.

That said, I am encouraged with select aspects of your health plan. You prioritize cost containment, propose divorcing health insurance from employers, and invoke the idea of tort reform.

Your plan takes a traditionally conservative, market-based approach to health insurance, emphasizing the use of tax credits and health savings accounts.

However like your Democratic counterpart, you do not address the primary care crisis. If your plan comes to fruition, patients will be more responsible for their health spending. Forget the fact that there currently is not enough transparency nor cost information available for many patient-consumers to make an informed decision.

Without adequate access to primary care, patients will be forced to choose care at more expensive venues and sacrifice preventive care. Health savings accounts will not be adequate for emergency room bills or prolonged hospital stays.

Senators, at a time where Baby Boomers are approaching age 65, the outlook on who will care for these new Medicare beneficiaries is dismal. A survey from the Journal of the American Medical Association found that two percent of graduating medical students say they plan to work in primary care internal medicine. Let me repeat that. Two percent:

The results of a new survey . . . suggest more medical students, many of them saddled with debt, are opting for more lucrative specialties.The survey of nearly 1,200 fourth-year students found just 2 percent planned to work in primary care internal medicine. In a similar survey in 1990, the figure was 9 percent.

Paperwork, the demands of the chronically sick and the need to bring work home are among the factors pushing young doctors away from careers in primary care, the survey found.

“I didn’t want to fight the insurance companies,” said Dr. Jason Shipman, 36, a radiology resident at Vanderbilt University Medical Center in Nashville, Tenn., who is carrying $150,000 in student debt.

Primary care doctors he met as a student had to “speed to see enough patients to make a reasonable living,” Shipman said.

I do not hear any solutions addressing this issue on the campaign trail. No suggestions to, i) reform the dysfunctional physician payment system which rewards expensive procedures at the expense of office visits for preventive and chronic care; ii) encourage medical students to enter primary care fields by forgiving their medical school debt; and, iii) fairly reconciling the wide chasm between specialist and generalist salaries.

The simple fact is that unless you solve the primary care issue, neither of your plans will be successful.

I look forward to listening to any proposals you may have to address the primary care crisis. I also wish both of you the best of luck as we come down the home stretch of a grueling campaign season. You don’t need me to tell you that every vote counts.

Mine’s up for grabs.


Kevin Pho, M.D.
Nashua, New Hampshire

topics: obama, mccain


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