Overcoming Hurdles to Health Access Including ACA

(And other 3 letter acronyms representing failure for the past three decades)

A nation divided continues to either promote ACA or protest it. Regardless of pro or con, many barriers to care remain as with health care designs 1983 to 2014 and beyond.

This post was stimulated by a recent family medicine piece reviewed situations facing practices in Sugar Land and Arlington in Texas. It is true that all practices face the challenge of patients who do not understand how insurance works. But there are substantial health access barriers that remain and ACA may actually complicate health access for those in need of care. Focus must be returned to the substantial health access failures with minimal distractions.

It is frustrating to see illustrations of practices in wealthier areas such as Sugar Land Texas. At these locations FM competes with a wide range of other providers for patients with insurance coverage better than ACA, Medicaid, and Medicare. It is not a surprise to see family medicine move steadily toward a focus on marketing – essential for competitive types of practices. But for those devoted to health access, the substantial resources involved in Primary Care Medical Home or other families of family medicine efforts could have been expended in ways that would have helped the half of family physicians where care is most needed.

Future of Family Medicine I, II, III… should be more about the incredible contributions of family physicians with regard to health access.

The great challenge of health care for our time is care for 40 – 50% of Americans who remain behind under state and national designs. Designs for the recovery of health access are the opposite of current US designs.

Family medicine leaders and various advocates of primary care, rural health, or care where needed may desire to praise the efforts of the current administration just like past administrations, but our primary responsibility is to the patients of family physicians and needed health improvements in our communities.

All family physicians should embrace a uniform approach to resolving health access involving improvements in who becomes a physician, how physicians are trained, and how they are supported – all specific to health access result.

Failure from Beginning to End

Factors important in distribution where needed are family medicine choice, residency in a state in need of physicians, medical school in a state in need of physicians, and physician origins associated with states and counties in need of care.

Linking up instate, permanent primary care FM, and training where care is needed is a solution. The chronological beginning step for improve health access is origin associated with counties in need of physicians.

When physicians arise from counties of need, they are more likely to be found in family medicine, primary care, and counties in need of care. Linear relationships exist from most to least.

Exclusive origins tend to fail for distribution.
Normal origins facilitate practice where needed.

Physician origins more closely associated with care where needed, primary care result, and family medicine result are about normal origins. Most exclusive physician origins are lowest yield for physicians to serve where needed. Solutions are about those multiple more times likely rather than those with reduced probability.

Texas is not different than other states in its failure to progress students arising from populations in most need of workforce. Physician origin failure is about most children left behind while fewer advantaged children progress to higher education and medical school. Widening gaps across the nation worsen this situation.

The US designs insure that advantaged children least like normal Americans have 2 – 8 times greater chance of admission and disadvantaged children (most children) have 2 to 4 times less (Birth Origins Studies). Widening gaps across income, education, health care, and other spending designs insure fewer doing well and more doing less well.

The probability of becoming a physician is made worse for children in states that have not invested as much at all levels from child development to early education to in higher education including medical education. Many medical schools have found ways to admit more students who are out of state in origin or otherwise least connected to the state. At Nebraska such students as well as those with Omaha or Lincoln origins have 2% family medicine choice – the opposite from the instate, family medicine, where needed solution for Nebraska.

American born children also have even lower probability of becoming a physician as 25% of entering US physicians are graduates of medical schools in other nations. International graduates also have limitations in distribution where needed and primary care result due to few choosing the only remaining permanent primary care source – family medicine.

Texas med schools (except for 1) fail for family medicine result - the only multiplier of care where needed. The medical schools that used to graduate family physicians in the 1990s across all states in need, now have substantially reduced FM production.

The US design for GME fails for primary care, for states in need of care, and for nearly all Texas counties in need of care.

A continuity design for preparation, medical school, and FM residency with pure FM result is increasingly the only solution – for the workforce component.

Workforce Design and Payment Design Solutions

The ACA design as with the past 30 years of designs has failed for the workforce needed and therefore fails for the care of populations in need of care. Solutions for health access recovery for most Americans must coordinate needed workforce with needed spending.

The ACA is a minimal benefit for payment for the services where needed. Medicaid expansion failure, return of Medicaid to lower reimbursement, cuts in disproportionate share, Medicare reimbursement too low for care where needed, and penalties for providers where needed represent continued failure by design.

The ACA remains in good company as with decades of failed designs.

The ACA designs, like SGR, DRG, national designs since 1980, still fail for support of primary care and workforce and spending where needed

Worsening Complexity and Numbers Where Care Is Needed

A 39% increase in the population since 1980 has been greater where care is needed, widening the care gap. The primary care design has failed for primary care delivery capacity increase, widening the care gap and preventing resolution of care where needed.

Now matters are worse.
  • Population growth – Population continues to increase faster where care is needed with lesser growth where clinicians are most concentrated.
  • Massive growth in demand for primary care is seen due to elderly populations and those rising to insurance.
  • There is no primary care response – due to fewer MD, DO, NP, and PA supported in primary care choices due to too little primary care spending and too much outside of primary care.
  • Basic services failure: the spending failure – pay for basic services, not the most specialized, is low. This results in declines in general surgeons and other general surgical workforce which are declining overall and especially in rural areas and counties with lower concentrations of clinicians.
  • Basic services failure: the workforce failure: Failures in basic services payment combine with fewer general surgeons, general ob-gyn physicians, fewer general orthopedists, and fewer core specialty trained physicians remaining in their general core specialty.

Generalists and general core specialties are the multiple times solution where care is most needed and where care demand is increasing at the most rapid rates.

This demand from the elderly, those rising to insurance, and those with more complex care needs will accelerate and will further overwhelm remaining providers where needed - where family docs are more likely to be found. The same factors that shape shortages of physicians and more family physicians also shape lesser health outcomes.

ACA penalties actually take away the payment support where care is needed due to value based, pay for performance, and readmission penalties.

ACA has not been helpful for rural hospitals and design changes have made matters worse. Already the nation is down one more rural hospital each month with the potential for hundreds more closed, as with DRGs and 1980s changes.

It is not possible to penalize providers where needed and move toward recovery of health access for greater than 40% of Americans behind by design.


The most specific health access solution is more family docs, trained instate in most states in need of workforce, arising from and trained in counties of greater need, and supported by a much better payment design. Maximal instate workforce for states in need, maximal primary care, and maximal workforce where needed – are about family medicine focus before, during, and after training.

Recent Works

Health Care Delivery Is No Laughing Matter

Will Teaching CHC Sites Deliver on the Promise of Health Access

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

Best of Basic Health Access

Robert C. Bowman, M.D.
www.basichealthaccess.blogspot.com 

World of Rural Medical Education at www.ruralmedicaleducation.org

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