With legal and political battles over the Affordable Care Act all but settled, it now appears that the health care overhaul law is here to stay. The goal of the law is to promise insurance coverage for more Americans and, if it works, increase access to care.
But doctors' groups in Connecticut and elsewhere say that having insurance doesn't necessarily mean greater access to a physician. They say the nation is suffering a shortage of primary care physicians. And the shortage may be even more acutely felt at community health centers, where the underinsured in urban and rural communities get their care.
Arvind Shaw's last office was an old supermarket turned into a health center. It worked... "And, yeah, dental was on the dairy aisle. And it was kind of cobbled together." Now, Shaw is proud to give a tour of the new Generations Family Health Center in Willimantic. The facility opened late last year, and he is its CEO. "This is designed only for one purpose. Designed by the staff, for the patients, to deliver only one thing -- and that's to deliver our primary healthcare. Medical, dental, and behavioral."
But even though he's got the facility he wants, he and others like him say they don't have the providers -- the doctors, nurses, dentists, and clinicians -- to serve all of the people they could. Shaw says there are several reasons why -- but one is simple. Primary care doctors don't make as much as specialists.
Then there's this -- doctors in private medicine get paid more than his doctors. "If you want universal healthcare you will get it. You will get it when the doctor who works over here will be paid the same as the private sector." And, once you get providers in the door, keeping them there can be tough. "The real idea is, how long do you want them to work here and how do you keep them here? And there are folks in the private sector who know that if they go back and do a subspecialty residency, they can end up being an interventional cardiologist and make $800,000 a year. And can you compete with that? Do we need to compete with that? I don't think so."
The challenges Shaw faces are not unique. Nationwide, the Association of American Medical Colleges says the country will face a shortage of 90,000 doctors by the end of the decade. The American Medical Association says the problem will be worse in rural areas and inner-cities -- where community health centers operate.
Deb Polun is the Director of Government Affairs and Media Relations at the Community Health Center Association of Connecticut. She says a lot of her members tell her the same story. "It's very difficult to recruit providers to their health centers. Some of it is geographically based. We have some health centers that are in very rural areas of Connecticut and it's difficult for them to attract medical providers."
Polun also says there's some irony in the Affordable Care Act, which has spent millions in Connecticut on building new health center facilities, but which -- as she sees it -- doesn't really provide for the hiring of more physicians.
According to the Kaiser Family Foundation, Connecticut has gotten nearly $45 million from the new law. The overwhelming majority of that has been for building infrastructure. "A lot of health centers are building new spaces or expanding their spaces and so they're able to put in the physical exam rooms. But the irony is if there's no providers to serve the patients, then we haven't fully solved the problem." Polun says a major obstacle in the way is that not many schools specialize in training primary care doctors.
Quinnipiac University is trying to change that. The Frank Netter School of Medicine at Quinnipiac University in Hamden is making primary care its major mission. The school's first class enrolls next August. Bruce Koeppen is its dean. "Well, I think if you talk to anyone across the country who is in medical education, they will all tell you there is a severe need for primary care physicians in this country. Some medical schools have that as their mission and that was the decision that Quinnipiac made."
Koeppen says only 15 percent of students graduating from medical school are anticipating a career in primary care. So his school wants to do a couple things. First, it wants to work with other providers -- nurses, physician assistants, physical therapists -- to rethink primary care. Also, Koeppen says his incoming students will be paired with a primary care doctor one half day a week for three years.
"Hopefully, some of those students who have a good experience in those community health centers will see that as their practice option once they finish their training." That's what Arvind Shaw, the CEO at Generations Family Health Center in Willimantic, is hoping for. He says if you want to end the shortage of primary care doctors, you have to look upstream. You have to create incentives -- both financial and educational -- that drive medical students to the practice. And you have to, eventually, consider community health a subspecialty like anything else...like cardiology, ophthalmology, radiology. "The system is designed exactly for the results that it's getting. So if you have a shortage, it's designed to have a shortage." Change the design, he says, and you'll change the outcome. At least, that's his hope.