Failure of Reagan Economics, Health Policy, Education, and More
Robert C. Bowman, M.D.
There are interesting articles about the failure of Reagan policies in areas such as economics and health care, but few are aware that the failures have continued with each new set of leaders since the 1980s. Improvement that was supposed to be shared by all Americans remained in the hands of fewer at the top. The deficits that the United States tolerated included basic access to health http://www.ruralmedicaleducation.org/images/insuffrecovery.GIF
From 1970 - 1980 the US was on course to rebuild health access by 2010 following the curve in the first graphic. This also demonstrated that the US could produce sufficient primary care, but has chosen not to do so. The result favored 35% of the population with 65% of the population left behind not only in basic access workforce, but in financial access.
Also the changes are difficult to track as they involve policies that impact all areas that shape health access workforce – birth to admission, admission, training, health policy, medical education, PA and NP design, graduate medical education, state policies, and more.
1978 - 1980 represents the beginning of the collapse of primary care. This falling off of the curve occurred after a quadrupling of annual graduate primary care numbers in the 1970 to 1980 period. In this period, NP and PA contributions were small and inconsequential but did involve 70% or more primary care for the graduates who generally were older, primary care in intention, primary care in training, and trained with primary care physicians in health access locations.
While a quadrupling of primary care numbers was substantial, basic Workforce 101 requires 35 years of sufficient production to reach enough primary care. The 35 year period is a generation of physicians from age 30 - 65. Anticipations of total physicians, translate as specialist physicians, usually is considered by workforce planners that live and work in top concentrations of specialists. Anticipations of primary care, most needed by the 65% of the population that depends upon primary care for 50 – 100% of local physicians, are rarely considered more than a few years in advance. This is quite tragic as specialty care has always been able to arise from primary care in the United States while primary care has always required dedicated planning and implementation and coordination decades in advance to have basic health access at all.
So the really bad news is that even if the US mandates sufficient primary care and starts producing the 12,000 - 13,000 graduates a year with 90% retention in primary care for 35 years, with 90% active for 35 years, with 90% of the volume of a family physician for 35 years, it will still take 35 class years of graduates to reach a steady state with sufficient primary care compared to the US population.
http://www.ruralmedicaleducation.org/images/PerFactorsPCDelivery.GIF only FM or a type of practitioner that meets the requirements of 90% or above in all areas (PC %, % active, % volume, % of 35 years) meets the recovery need as well as rural and underserved need.
If you prefer to see percentages that actually result in primary care delivery as a Report Card with Grades, here is a Health Access Report Card including rural and underserved distributionhttp://www.ruralmedicaleducation.org/basichealthaccess/Health_Access_Report_Card.htm,
As anyone can easily discern, there are clear choices for real primary care delivery, real rural workforce, and real underserved workforce.
Family medicine comes closest to a US health access recovery vehicle with permanent primary care most likely, with slightly lower than 90% at 86% active, but making up the difference with 100% or top volume primary care. This results in 25 Standard Primary Care years even when including some losses for foreign origin IMG who deliver half of the workforce of US graduates. Rural and underserved distributions are consistent for family physicians across all populations and steady for all class years of graduates. This is not the pattern seen in other forms with declines in primary care, rural, and underserved.
So if we kept on track during 1980 and beyond for Reagan and all Presidents and Congresses beyond using family medicine or a permanent family practice design for NP and PA, we would have had sufficient health access in 2010. But since we were led a different way and tolerated being led a different way and designed a health plan that fails in health access in the 4 dimensions (facilities, health care team members, physicians, lower and middle income financial access), we designed failure in health access.
A major design failure was the flexible training form design of primary care. We now have 22,000 annual graduates in IM, NP, and PA that end up in primary care about 20% of the time. We chose flexible primary care with graduates that tend to ignore primary care while they are found 70 - 90% in specialty care. The US initial design for NP and PA was a broad family practice generalist practitioner for health access. The only reason that NP and PA survived the first critical decades to become new forms of health professionals is because of federal and state legislation mandating their creation and support and development. Their potential for health access was high, but they have left health access as any common sense review would reveal.
You cannot be a primary care source with less than 35% of graduates in primary care (family practice, internal medicine, and pediatric primary care) or 40% if you want to add geriatrics to this.
The US has allowed this non-physician vehicle of health access to be subverted into a profit vehicle for hospitals and specialists who can generate more revenue using NP and PA specialists. The NP and PA contributions to facilitate health access working closely with family physicians in rural and in underserved areas were stellar, decades ago. Now the same benefits are seen for specialty physicians and large systems, who profit from converting all primary care to higher reimbursed specialty care. The flexible primary care training forms of IM, NP, and PA are ideal for the many purposes that they have or can find to generate more revenue. These savings have not been passed on to consumers or government.
Since NP and PA benefit with 10% or greater increases in income by leaving primary care, better benefits, better working conditions, and better support personnel all shaped by policy, they will continue to depart even with primary care reimbursement increases. NP and PA contributions included capturing market share and teaching volume through primary care contributions in the managed care gatekeeper model. In the new model since 2000, the NP and PA contributions are to gather market share and teaching volume in hospital and specialty care. By funneling in more patients to more subspecialized physicians and systems, even more profits can be generated. Also local primary care with insufficient support, has come under the control of larger systems who supplement the primary care to funnel specialty patients their way. The current ER, urgent care, and primary care design is consistent only in funneling care vertically with horizontal health access needs and local control and influence subverted. True health access is about local design and influence with coordination for secondary and tertiary needs. The US insures subspecialty and destroys basic health access in the current design, especially in physician and in non-physician workforce.
http://www.ruralmedicaleducation.org/images/ProduceNonPC.GIF This demonstrates that physicians and non-physicians that are not in primary care continue to multiply rapidly while the primary care (especially family practice types) remain with fewer graduates to serve the population. Not shown is the US population increasing not quite as fast as specialist physicians and non-physicians, but far outstripping the flat lack of growth in primary care.
IM is only 10% primary care for graduates now, NP is less than 33%, and PA is less than 25%.The levels have declined for decades and will continue to decline. http://www.ruralmedicaleducation.org/images/FailPCFlex.GIF
What is worse, the "experts" consider these the future of primary care even though with each class year and each year after graduation they are found in lower and lower primary care percentages tracked over the last 30 years and especially the last 10 years. The departures in the studies by associations (AAPA, AANP, AAMC, AMA), by Larson and Hart in PAs, have always been the most dramatic in the family practice component most responsible for rural and for underserved workforce (especially both). Even during 1990 to 2000 with better primary care policy and improved reimbursement, family practice PAs departed steadily.
NP and PA changes since the 1980s have always been greater increase in specialty care than in primary care, and eventually gains in only specialty care with losses in primary care. http://www.ruralmedicaleducation.org/images/DecreaseNPPA88to08per.GIF
Failure in policy design and failure in primary care retention is the rule.
This next graphic is most relevant now with some reform considered. Even with a relatively substantial change in reimbursement for primary care and even a punishment to specialty care, it was only a slight bump on changing declines in primary care delivery per graduate.
http://www.ruralmedicaleducation.org/images/PCDeclineDespite1990s.GIF Do not expect any real change from the current Congress or President as the nation does not even understand real health access or real primary care and current workforce leaders have a vested interest not to reveal the massive failures, especially those who consider internal medicine as primary care (and want billions more as they profit off of ignorance that internal medicine graduates are no longer primary care sources).
Recovery is possible and we do not need to experiment. Common sense dictates the policies of permanent primary care that result in reliable primary care. Comparisons of primary care that is permanent compared to temporary are needed. This is a graphic comparing 2 methods of primary care recovery. http://www.ruralmedicaleducation.org/images/RecoveryTwoInterventions600k.GIF
The graphic illustrates the futility of attempting health access recovery with flexible forms. The US would need 30,000 to 40,000 more annual graduates spread across the three flexible forms - in IM (8000 to 18000), in NP (7000 to 17000), and in PA (7000 to 17000) - to result in a workforce of 1.2 million graduates by 2050 that might meet primary care needs. More likely it would still be insufficient as IM, NP, and PA move away from primary care.
A real health access recovery plan is possible and proven. A second method would result in 5000 more family medicine residency graduates a year or 8000 total. This would more reliably result in sufficient primary care after 35 years of such production. It would likely take until 2020 to get this in place.
Regardless of the type of primary care, the need is to protect primary care from destruction to become specialty, hospital, hospitalist, locums, urgent, and emergent care. The current design benefits brokers who deliver no health care and profit off of desperation as more and more Americans fail in basic access to health.
Bob Bowman
rcbowman@atsu.edu
If you would like slides of these, email me
All the above and more graphics at www.basichealthaccess.org This is a health access site for all Americans, especially the 65% of the population and 70% of the elderly left behind by the health access workforce design.
One man can make a difference. Every man should try. John F. Kennedy
Blueprint for recovery in relationships http://www.unmc.edu/Community/ruralmeded/kennedy_and_crisis.htm
