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Sen. Bernie Sanders: Health-care bill could spark "a revolution in primary health care"


Tell me a bit about the provisions to expand community health centers that you added into the Senate bill.

In most areas of Vermont right now, you can drive to a community health center near you where you’ll get excellent quality primary health care. If you have no health insurance, you’re charged on a sliding scale basis. If you have Medicare or Medicaid, they’re delighted to have you. And private health insurance, that’s great, too. We’ve gone from two community health centers in Vermont to eight. And those eight centers have 41 separate locations and are used by about 100,000 people – and that’s in a population a bit over 600,000. So we know they work.

As of this point, we have added $10 billion for the program in the Senate bill. Congressman Jim Clyburn has added $14 billion in the House bill. And my hope is the conference committee will go with the $14 billion. What we would do with $14 billion is expand access from the current 20 million people served by community health centers to 45 million people. It will mean establishing CHCs and their satellites in 10,000 new communities. What it also means is that we will dramatically increase funding for the National Health Service Corps so we have an additional 20,000 doctors, dentists and nurses. It’s a revolution in primary health care if we get what I hope we get.

Let’s focus on that for a second. One of the issues in the health-care system that hasn’t gotten enough attention is the focus on specialty medicine. Those doctors make more money, so more and more medical students are going in that direction, but they also cost a lot more money, as they create demand for expensive procedures. I’ve heard people say we can afford a universal primary-health-care system, but not a universal specialty-health-care system.

We need to expand the National Health Service Corps. If you go to the University of Vermont, you’re going to graduate with $150,000 in debt. So you become a specialist and make a lot of money and repay the debt. But we’re going to give the NHSC enough money to forgive the debt of 20,000 students to practice in underserved communities. The other thing we need to do is raise the reimbursement for primary-care doctors.

And these community health centers are sort of seen as a front line for access to primary care?

When we talk about health care, people tend to talk about insurance. But equally important is access. You need to be able to find a primary-care physician and a dentist and a mental-health counselor. The $14 billion will have a profound impact on addressing the crisis in primary care in this country. We’re not graduating enough primary-care doctors, and even people with insurance often can’t find one. But the insanity is that we’re not just depriving people of primary care they need, but we’re sending them to the emergency room. And the emergency room will treat you for the common cold and charge $600 to $1,000, and the community health center will cost $100. If we spend on community health centers, you actually save money.

We also have a major problem with dental care in this country. But community health centers provide that, and so, too, with mental-health counseling. They also provide some of the lowest-cost prescription drugs in America. This program, ironically enough, has widespread bipartisan support. Even George W. Bush put money into this program. John McCain campaigned on it. In the stimulus package, we doubled funding to about $2 billion a year and brought it up to $4 billion.

How much of a funding increase would the $14 billion represent?

It’s over five years. The $2 billion would have been $10 billion for that period. The $14 billion of new money is on top of $10 billion. So we’ll have more than doubled the size of the program. And that includes going from 100 million to 300 million for the National Health Service Corps.

Alongside the community health centers, where else does the bill have room to be improved in conference?

I won't be on the conference committee so I won’t speculate. My main focus right now is to get the $14 billion for this program.

Photo credit: Win McNamee/Getty.

By Ezra Klein  |  December 30, 2009; 3:00 PM ET
Categories:  Health Reform , Interviews  
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"If you go to the University of Vermont, you’re going to graduate with $150,000 in debt. So you become a specialist and make a lot of money and repay the debt."

This is wrong and has to stop being part of the thinking.

For oversimplified numbers:

PCPs make $100-150K
Specialists make $200-400K

Education is a one-time $200K cost.

Forgiving the debt may move things towards primary care slightly, but the overall dynamic remains. No doctor, after having sacrificed their full 20's to get there, is going to be content losing half their earning power in exchange for what amounts to a year of salary.

So debt relief is a terrible band-aid on a tough problem. The "right" answer is to bring down specialist salaries and complement PCPs with more nurses (not doctors) to work in a coordinated fashion More money for PCPs is frankly not necessary. The physician lobby has been extremely effective with the current DC folks is holding off alternative work models where physicians are only one part of the equation.

PS Medical education reform is badly needed. But that requires folks in DC to stop almost exclusively relying on academics for their policy ideas. Academics are a large part of the problem, as their parochial financial incentives are clear obstructions from meaningful change to the system. You're not going to get a David Cutler to say that four years of medical school and multiple years in residency training aren't necessary. But you simply can't talk about changing physician compensation without changing the training model. No intelligent person with options is going to choose medicine if it requires being the best in college, 4 years of medical school and 3-10 years of below minimum wage 80 hour weeks. A reasonable training model coupled with reasonable compensation reform could work, on the other hand.

Posted by: wisewon | December 30, 2009 4:02 PM | Report abuse

Yes, the debt relief for graduating doctors is a small thing that will do little for the rest of us.

Community medical centers are a very wonderful thing to have. Truly wonderful. But they are completely useless for the higher-ticket items, such as cancer treatment or any type of mid/major surgery - the things that bankrupt people.

Posted by: seatek | December 30, 2009 4:48 PM | Report abuse

well I got excited until I read wisewon's comment.

But I am glad to see attention go to primary care. I think growing awareness of the shortage of PC practitioners, coupled with an understanding of the cost benefits of primary care, has to be good.

Posted by: rosshunter | December 30, 2009 4:48 PM | Report abuse

Hire fewer MDs and more PAs and RN Practitioners.

Bernie refers to dental and mental health care ... are those services actually going to be covered in the bill??

Dental and visual, I believe, will be removed with deletion of Medicare Advantage, no?

Posted by: onewing1 | December 30, 2009 4:51 PM | Report abuse

Much more money is necessary to attract medical students to primary care. Money, prestige, and lifestyle are the major determinants of specialty choice. We can't do much about lifestyle, so we need to double or triple primary care salaries to make them competitive. I agree with wisewon that you could shave off a year or two at the high school and college level to make medical trianing less of a hardship.

As for community health centers, they're a small piece of the puzzle that will provide care for those who remain uninsured. They're a good place to train students since the patients are appreciative and the acuity is low. Nobody thinks CHC's can provide comprehensive longitudinal care.

Posted by: bmull | December 30, 2009 5:17 PM | Report abuse

Loan forgiveness is nice, but not likely to have much effect. Primary care is looked down on as failure to obtain further training rather than a training goal itself. In Europe, that's not the case. You choose to go into primary care or you choose to go into specialty care, you don't train as a generalist first, then a specialist.

I can think of several ways to improve efficiency. For one thing, don't train as many specialists. The federal government controls the number of specialist training positions every year because the federal government compensates hospitals for training. The fed needs to reduce payment for specialty fellowships. If you can't get into a specialty fellowship, you'll go into primary care.

Train more primary care doctors and train them better. Allow physicians in training to view primary care as a respected "specialty" rather than the fall back for losers. Substituting less well trained NP/PAs for generalists just results in continuing the practice of primary care as specialty triage. Ideally, you need primary care doctors that have a broad and deep level of knowledge to manage chronic care. NP/PAs are more appropriate for specialty care, routine procedures (e.g. colonoscopies!), and limited scope activities (e.g. low risk pre-natal care).

Acknowledge that not every medical problem is curable and that everyone dies. Protect primary care docs from malpractice when they do the right thing. Right now, if I take care of a 400 lb diabetic who "forgets" to take his medication and he drops dead of a heart attack, who gets sued for failure to refer in a timely manner? Would a cardiology or endocrinology referral really have prevented his death? What if I see a heavy smoker one time for a bladder infection and tell her to follow up with her regular doc to rule out bladder cancer and four years later she gets lung cancer, can I be sued for failure to refer to a pulmonologist? (The first example is hypothetical, the second one is real.) Malpractice IS part of the problem and yes, I understand that "tort reform" has no prospect to solve the problem and the cost of malpractice insurance is minimal in the larger context.

Posted by: J_Bean | December 30, 2009 5:49 PM | Report abuse

"well I got excited until I read wisewon's comment."

He makes it a lot. (I'd like to know when wisewon qualified.) And I'd also note that the PCPs at this year's NHSC loan repayor conference would beg to differ.

Anyway, J_Bean points to the cultural problem by which generalists -- considered the linchpins of care in countries with actual healthcare systems -- are regarded as med-school failures in the US. It's difficult to change that without stuffing generalists' mouths with gold.

Posted by: pseudonymousinnc | December 30, 2009 7:08 PM | Report abuse

You know, wisewon has made this point to Ezra again and again and again, and it just doesn't seem to register with Ezra: the financial incentive of loan forgiveness is a drop in the bucket compared to the sheer financial incentive of getting a specialist's salary in the first place.

J_Bean's observations are the more pertinent ones here when it comes to incentivizing primary care: the primary care issue needs a systemic solution, rather than relying on the hope that med school students won't be that good at math.

Posted by: tyromania | December 30, 2009 11:23 PM | Report abuse

I'm not so sure about stuffing their mouths with gold. Specialist vs. generalist pay is no different in the U.S. than it is in Europe. There is something else driving the difference. One of those things is the over-production of specialists -- many of whom wind up providing what is essentially primary care -- and the other problem is cultural. The first issue is easy to correct. The second is much more resistant.

Posted by: J_Bean | December 31, 2009 10:29 AM | Report abuse

The reason people seek out specialists for problems that don't require specialists is that they don't see any of the additional cost. If it truly cost the patient more to see a specialist, instead of that cost being hidden and buffered by Medicare or a $10 higher co-pay, we would see consumers choosing the better value option.

Yes we should see a specialist when we need a minor surgery, but much of what we all pay more for in gynecologists, dermatologists, and allergists is not a good value proposition. I would definitely pursue more value based medical decisions were I given an incentive to do so.

Posted by: staticvars | December 31, 2009 11:39 AM | Report abuse

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