Critique of Commonwealth Fund Report on Ensuring Equity

A Critigue of Ensuring Equity    A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations


A firm reminder to Commonwealth and governments and associations: No matter what you think about primary care or health access, to have primary care or health access someone must be there to deliver the care.
 This foundation sponsored report attempts to focus attention upon bringing equity to health care. This is a most important area, but the report fails to mention primary care workforce other than the following:
  • Additional efforts may be required to develop the workforce pipeline, such as an expansion of medical education debt relief for primary care providers, specialists, dentists, and others practicing in health centers, safety-net hospitals, and medically underserved areas. P12 also repeated on p39 
  • Additionally, efforts may be needed to increase the number of physicians and allied health professionals available to deliver such care. P14 also repeated on p41 
  • Expanding the work­force and engaging the private sector’s providers to serve vulnerable populations is critically important as people gain health insurance under the Affordable Care Act. P24
Schools and students may need debt relief, BUT PEOPLE NEED HEALTH ACCESS. And this requires workforce. And this requires that the workforce be in position. With only 25% of workforce found in 30,000 zip codes with 200 million Americans (65%), serious design flaws exist.
Like Health Affairs issues devoted to Disparities (October 2011)  and to Primary Care (May 2010) as well as other government and foundation reports, the reports fail to indicate how the nation can get to health equity. To actually innovate, reorganize, reform, or change health access, first and foremost there must be
  • Primary Care Workforce and a specific type of workforce: Family Practice Workforce
In this report as in almost all other similar works, there is little attention paid to the family practice RN, MD, DO, NP, and PA requirement for a move toward equity. Family practice of all types can be found with 50% or greater proportions practicing in 30,000 zip codes with 65% of the United States population. Family practice is the local zip code or adjacent zip code solution because of its stellar distribution. In many ways family practice is repelled by practice locations with top concentrations of workforce resulting in much greater distribution.
Primary care not family practice barely reaches national average distributions at half the distribution of family practice.  Internal medicine and pediatric primary care is found 70% in 3400 zip codes clustered together in less than 4% of the land area with only one third of the United States population. This compares to 72 - 75% of total US workforce found in such top concentrations. The elderly, poor, near poor, rural, lower income, middle income, disadvantaged, underserved, and Community Health Center populations are all greater than 65% found outside of concentrations. Non-family practice is out of position to facilitate health equity.
Primary care broadest generalist that stays broadest generalist for an entire career is required and only family medicine meets these two criteria. Family practice employed PA and NP work just as well, but only when staying in family practice. The family practice physician assistant is 30 times more likely to be found in rural health clinics and is 6 – 7 times more likely than other PAs to be found in Community Health Centers. No other type of PA reaches beyond the 15% of physician assistants found in rural areas and family practice PAs are found in rural locations at 30%. Family nurse practitioners are not only the dominant primary care source, they are the dominant rural and underserved component also. Unfortunately only 25% of generic NP or PA graduates contribute as family practice.
Family practice physicians are twice as likely to be found in all underserved locations, are 2 to 3 times more likely to be caring for the elderly and others left behind, and are 3 to 4 times more likely to be found in rural locations compared to other types of physicians.  In the graduates of each US medical school family practice multiplies health access. Across all birth origin types, family practice multiplies health access. This consistency is found for the past 40 class years of family medicine. Because NP and PA proportions of family practice continue to decline, the health equity contributions have decline - by at least half in the last 30 years. More and more graduates are required to achieve the same result for NP and PA. 
If the nation really priorities health equity with primary care retention and primary care distribution as top priorities, it would have expanded family medicine. Instead family medicine remains at the same 3000 annual graduates first reached about 30 years ago.
Generic Fails for Health Equity, Specific Is Required
Other sources of primary care are first of all not able to remain within primary care and second of all they are not capable of the distribution required to deliver on promises of health equity. The United States cannot resolve equity by graduating more that deliver more non-primary care than primary care and by graduating more that barely reach the national average regarding distribution where needed.
More generic primary care will not address health equity. Nurse practitioner and physician assistants sources are dilute sources for health equity. More generic nurse practitioners result in only about 1 in 4 that serves in family practice direct practitioner care with only half of these serving where most needed. More generic physician assistants results in less than 25% family practice with again only half of these found where needed. More generic osteopathic graduates result in less than 17% family practice. Despite the recent doubling of osteopathic graduates the decrease from 35% to 17% family practice has negated health access gains. More generic allopathic (US MD) graduates result in 7% family practice. A decline from 14% to 7% defeats health access and expansions will not make up the gap. Only 10% of registered nurses are in primary care and even fewer are found in family practice settings and those found where needed are cut in half again.
It is not enough to think good thoughts.
Actions are required that bring thoughts into reality.
SMART Basic Health Access

Ensuring Equity
Equity is a core goal of a high performance health system. However, there is a growing health care divide in the United States, where vulnerable populations—those lacking health insurance, low-income families, and racial and ethnic minorities—are at higher risk for poor health and poor health outcomes than the rest of society. The Affordable Care Act will expand insurance coverage and bolster the parts of the health system that serve vulnerable Americans, yet much work remains. This report from The Commonwealth Fund Commission on a High Performance Health System examines the problems facing vulnerable populations and offers a framework for moving forward. It features three overarching strategies to close the health care divide: 1) ensure that health coverage provides adequate access and financial protection; 2) strengthen the care delivery systems serving vulnerable populations; and 3) coordinate care delivery with other community resources, including public health services.
Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely


  1. Commonwealth Again Invests in Innovation, But Where's the Beef - the Workforce to Deliver the Care

    The New Wave of Health Care Innovation

    The Affordable Care Act will transform the U.S. health care system in many ways. A new Commonwealth Fund–sponsored supplement in Columbia Journalism Review looks at how hospitals, physicians, employers, insurers, and states are preparing for the changes ahead and experimenting with approaches to improving access and quality and controlling rising health care costs.


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