The Affordable Care Act’s (ACA) Challenge for States: Securing Primary Care Services

The New England Journal of Medicine ( contains the article, The State’s Next Challenge– Securing Primary Care for Expanded Medicaid Populations, by L. Ku, Ph.D., M.P.H. and others from the Department of Health Policy, George Washington University, Washington,DC. Although the statistical data in the article and analysis of same may well be correct, it doesn’t offer any practical solutions, and the meaning of its rhetoric remains disguised.

(The sentences in italics are from the article; the non-italicized parts are my commentary.)

(Page 1. of article) However, since many of the states with the largest anticipated Medicaid expansions are also the ones that have less primary care capacity, they could face surging demand from the newly insured without having sufficient primary care resources available. These gaps could affect access to care not only for the newly eligible Medicaid beneficiaries but also for others who depend on a state’s existing supply of clinicians.
One solution for this could be to ask the specialists in the state such as cardiologists; lung and kidney specialists; gastroenterologists; endocrinologists; etc. to provide primary care services as well as specialty services for the patients in their region. To receive certification from the American Board of Internal Medicine (ABIM) in one of these specialities requires that the physician must be previously certified in internal medicine by the ABIM ( Physicians in internal medicine are considered to be primary care providers. The specialists are trained internists to begin with and are certainly capable of providing the primary care services that internists provide. If this happened, it could effectively delete one layer of back and forth referral (substantial cost savings) and the patient could receive both levels of service, primary care and specialty care from the same doctor, who by definition has advanced knowledge. I wonder if this would help doctors to see patients as whole human beings instead of as the man with kidney failure, the woman with anemia, etc.
Some other thoughts regarding this potential dual role for specialists:
1. Increased Medicaid fees for primary care services to 100% of Medicare rates in 2013 and 2014 is not adequate. It should be permanent.
2. The payment of these fees should be electronically immediate without the ridiculous paperwork required from doctors’ offices, which greatly increases their overhead.
3. The increased Medicaid fees should not be restricted to primary care services but extend to specialty services as well.
4. Of course, one must realize that if something like this happened, i.e., patients actually being seen for their illnesses by a doctor with advanced knowledge, this could effectively end the Gatekeeper Concept, which would disrupt one of the underlying cost-control plans of the ACA and of the health care reform experts of both the private and government payers: Herd people into primary care holding pens like cattle and restrict their access to specialists.

(Page 3. of article) Many of the highly challenged states have a lower-than-average ratio of advanced practice clinicians to primary care physicians, so are less able to utilize efficient team-based care.
Well, if a specialist was delivering primary care services and specialty care services, the entire doctor part of the team could be wrapped up in one person, unless other specialists’ knowledge were required. I have written previously about how medical school and post-graduate training programs could be arranged to provide this degree of training as opposed to ending post graduate training at the primary care level (Chapter 6 of Equal Health Care For All (copyright 2007)

(Page 3. of article) Many (states) also have limiting scope-of-practice laws that restrict nonphysician clinicians in places where their skills are most needed, as the Institute of Medicine has recently noted.
My view is that ‘nonphysician clinicians’ is a paradox in terms. True clinicians have gone to medical school, received an MD degree, and participated successfully in post-graduate training programs of several years duration, resulting in certification in one or more specialities. The nonphysicians, who see patients, do not, in my view, deserve the title of clinician and should be employed by and supervised by the same physician, who accepts ultimate responsibility for the quality of their work.

(Page 3. of article) The ACA takes a fundamental first step toward improving access to care by expanding insurance coverage.
I presume this statement includes the expanded Medicaid population as ‘covered by insurance’. The reason for making this presumption is that expanding the Medicaid population will allow insurance companies to raise their premiums and deductibles and pursue other dollar-garnering mechanisms, which significantly and adversely affects those people, who actually do purchase health insurance, either individually or through their employers as part of their wage. Ideological cover for this greed is provided by the cost-shift argument. I discuss the cost-shift, the concepts of the business of medicine vs. the medicine of medicine, and how the American healthcare system already is, effectively, socialized in my new book, Socialized Health Care Reform, copyright 2010.

Another antagonistic, in my view, accomplishment of the ACA is that it leaves in place a main aggravating factor for ongoing discrimination in our healthcare system: The concepts of entitlement population, indigent, and poor in our medical lexicon, while expecting the people in the USA, who actually pay taxes, to pay for it with those taxes. If the ACA is so laudable, why didn’t it offer a ‘public option’ for everyone, in which everyone could participate and which would use the power of volume leverage to control the exorbitant prices paid to hospitals (FP and NFP), pharmaceutical and technology companies, and other healthcare businesses. Surely this also could have been the death knell for health insurance carriers, which cause so much misery. The public option could bring control to, ‘socialize’ the business of medicine.

There seems to be real worry in this article over whether we will have enough primary care physicians to handle the changes the ACA brings upon us. Is that the worry or is it worry over the final curtain for the Gatekeeper Concept because there won’t be enough primary care physicians to keep everyone in primary care holding pens and restrict their access to specialists. Gosh! Then the payers, both government and private, would hit a major obstacle in their ongoing efforts to ‘socialize’, control the function of, doctor patient relationships, the medicine of medicine, by restricting which type of doctors patients can see.

Could this be the start of true healthcare reform: A Public option coupled with not enough primary care physicians causing the opposite effects of our current system, which so gloriously privatizes the business of medicine and so surreptitously tries to socialize the medicine of medicine, the doctorpatient relationship, no matter which payer is up to bat?

Now the question I have for the authors of this article and for the editorial board of the New England Journal of Medicine is this: Are you part of the ongoing rhetoric and spin, which disguises the real meaning and effect of the ideological farce called the Affordable Care Act, or are you just, as General Honore says, “STUCK ON STUPID?”

R. Garth Kirkwood, MD

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