The primary care problem, shown in charts

The greatest threat to the health overhaul might not be the Supreme Court or the shifting alliances of an election year. In the end, it could be a lack of medical providers. These charts explore the current surge in primary care interest, how we got here and whether it’s enough to diffuse the health law’s biggest threat.

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For the White House, training more primary care doctors is an especially high priority. Decades of research have confirmed that more specialists leads to more specialty care, which leads to a more expensive system. Now, with the passage of the Affordable Care Act, tens of millions of previously uninsured Americans will be looking for a primary-care doctor.

/ Source: Congressional Budget Office

The structure of the medical residencies also presents a challenge to increasing the number of primary care doctors. Medicare covers the lion’s share of the cost of training medical residents: In 2011, it spent over $9.5 billion on residents’ stipends, teaching physicians’ salaries and related overhead. But in 1997, the Balanced Budget Amendment capped the number of residency slots Medicare would fund (up until then, the funding had been open-ended). A recent study in the Journal of the American Medical Association found that the number of residencies stayed flat for five years afterward. When the number did start rising, in 2002, it was largely in specialty fields.

/ Source: The Robert Graham Center

The health overhaul, some hoped, would address that issue. But with the health insurance expansion’s $971 billion price tag — and the Obama administration goal to keep the law’s cost under $1 trillion — the funds didn’t turn up. And that has left the country with a looming shortage of doctors. By 2020, the Association of American Colleges expects the country will have 91,500 fewer doctors than it needs.

/ Source: Journal of American Medical Association

There are, however, some reasons for optimism. Something surprising started happening about two years ago: More and more American students began pursuing careers in primary care. After decades of decline, the number of American doctors matching into family practice residencies has been increasing since 2008. Since doctors salaries have not changed, many attribute it to the increased focus the health reform law put on the importance of prevention and public health.

/ Source: National Residency Matching Program

Increased student interest may not be enough to address the primary care doctor shortage. In the scope of a $1 trillion overhaul, the White House’s main effort on this front seems modest: a $167 million sliver of the $15 billion Public Health and Prevention Fund. That effort, the Primary Care Residency Expansion (PCRE) will train 889 doctors over the next five years. It’s something, but likely not enough: By 2015, the Association of American Medical Colleges predicts that the country will have 28,900 fewer primary care doctors than it needs.

/ Sources: Health Services and Resource Administration; AAMC

What happens if the country doesn't train more primary care doctors? Health costs probably continue to rise. Decades of research have confirmed that more specialists leads to more specialty care, which leads to a more expensive system. A study last month found that physician visits that result in a referral to a specialist jumped from 41 million in 1999 to 105 million in 2009, an increase of 159 percent. As the above chart shows, primary care physicians have begun referring to specialists more — and specialists have become more likely to refer patients to other specialists.

/ Source: Archives of Internal Medicine

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