Turn the pyramids right side up

Let’s take the best-case scenario: Healthcare reform legislation includes a strong public option and a path to healthcare coverage, finally, for the 50 million Americans who have none today.  

That day will be one that I and others have fought for over a long period of time. But before we get ahead of ourselves we are going to have to address: How are we are going to do it?  Practically and pragmatically, what do we need to consider now to make healthcare reform actually work?

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First, a public option must be both cost-effective and medically effective and that means there has to be an emphasis on primary care. Someone recently painted a rhetorical picture in a conversation with me that is worth sharing. Today, healthcare is practiced and built upon an inverted pyramid. With the apex at the bottom, the entire system is teetering on a fragile, wobbly and insufficient reliance on primary care; the system today is top heavy, relying too much on expensive tests and procedures often meant to avoid medical malpractice as much as to advance medical practice.  There are not enough primary care doctors in the United States and not enough time to see the patients already in the waiting room. What happens when we add 50 million people? Without an immediate and significant emphasis on primary care we are going to break the system. The inverted pyramid that is healthcare today cannot support the additional weight.

What we must address in coming comprehensive healthcare reform legislation is an overhaul of primary care in this country, from how we recruit and train doctors to how we pay them when they begin to practice medicine. The pyramid has to be turned right side up, with a solid and broad base that is built upon primary care, moving up to the specialty practices. Primary care is the key to reforming health care in America.

Today, the average medical student graduates at least $200,000 in debt. What happens next makes perfect sense. That new doctor, deeply in debt, is forced to make decisions on where he or she will practice based on a loan repayment schedule. While they may want to practice in an underserved area, the overwhelming debt places demands on the individual that cannot be ignored or even postponed. But what if a healthcare overhaul included free medical school tuition for four years in exchange for primary care service after graduation in an underserved area? I’ve introduced just such a bill and we know it can work, because we already have examples in which students receive an education in exchange for a commitment to pay back civil society.

Adding 50 million Americans to our healthcare system will require more primary care doctors, a lot more. Today, the French healthcare system is considered the best in the world by the World Health Organization and in France there is one doctor for every 400 patients. If we try to get even close to that ratio in the U.S., you quickly realize we have to dramatically increase our efforts to recruit, educate and retain primary care doctors if we are going to treat 50 million new patients. That means we have to address the issue of reimbursements.  

This too is an inverted pyramid today, with a much great financial emphasis and return on expensive tests and treatments as opposed to office visits and preventive care. But we have to stress preventive care in health care reform and that will be hard to do under the current system.  

Without preventive care as a foundation for our health care system, we will continue to see millions of Americans wait to get medical care until their condition becomes too serious to ignore any longer, and the cost for providing health care at that point will be dramatically higher.  

We’ve got to emphasize primary care and preventive care and the only way to do that is to re-engineer the healthcare system to make a doctor’s office sustainable based on seeing patients first and foremost.

Several ideas and models exist today that are worth exploring, such as community clinics in the cities and direct practices. In all of this, the key is making sure that any proposed solution can be replicated and sustained on a broad national basis.

America’s healthcare system along with the American people has been suffering under an outmoded and ineffective system that is crumbling at our feet. This is the best opportunity we have had in decades to fix it, but unless we address primary care as part of a strong public option everything we do will fall short. The best-case scenario holds out much hope and promise, so long as we invert the current model and put healthcare on a firm foundation that can support the needs of the American people. We can do it if we have the political will.



McDermott, a member of the House Ways and Means Committee, is a medical doctor and child psychiatrist.