In 2009, I was included in Esquire Magazine’s annual year end Best and Brightest list of about 20 people they think are doing wonderful things. It’s still one of my professional highlights. One of the others that year was a gentleman named Daron Acemoglu. I was fortunate enough to sit next to him for about a three hour dinner and drinks shindig put on by Esquire. Needless to say, he’s an impressive guy and currently known as the hottest economist out there. He’s just published a book called “Why Nations Fail.” The essential argument of the book is that “the wealth of a country is most closely correlated with the degree to which the average person shares in the overall growth of its economy.” According to Acemoglu’s thesis, when a nation’s institutions prevent the poor from profiting from their work, no amount of disease eradication, good economic advice or foreign aid seems to help:

I observed this firsthand when I visited a group of Haitian mango farmers a few years ago. Each farmer had no more than one or two mango trees, even though their land lay along a river that could irrigate their fields and support hundreds of trees. So why didn’t they install irrigation pipes? Were they ignorant, indifferent? In fact, they were quite savvy and lived in a region teeming with well-intended foreign-aid programs. But these farmers also knew that nobody in their village had clear title to the land they farmed. If they suddenly grew a few hundred mango trees, it was likely that a well-connected member of the elite would show up and claim their land and its spoils. What was the point?

This reminds me so much of physicians in America. Primary care is in such a bad state. Only about 5% of graduating residents are choosing primary care mostly because primary care doctors can expect to earn $3.5 million less than a specialist over their lifetimes. There’s really no rosy future that suggests this will get better. Currently, our medical industry is composed of 75% specialists and 25% generalists, exactly opposite of the UK and Canada, both of which rank much higher than us in nearly all health statistics. In the next decade or two, when boomers retire, primary care is essentially dead. And this is the elephant in the room for Obamacare. Obamacare depends on primary care to control costs, by creating the theoretical Accountable Care Organization. With only a tiny fraction of the physician workforce being primary care over the next decade, the ACO model falls apart. 

Now back to Daron’s theory. The medical industry is 20% of our economy. It alone is something like the 4th largest economy in the world. Let’s say that the primary care doctors are the equivalent of these Haitian mango farmers. Why would they try to put any effort into making their little corner of the industry any better when, at any moment, they’ll get squashed by the specialists and the other folks in the industry who are much more politically powerful? 

As one of my favorite doctors in all the world, who happens to be a primary care doc, recently said to me, “The hospitals…they always win.” There’s a was a sadness in her voice, a defeat. 

But Acemoglu isn’t pessimistic. In fact, he said he’s enthralled by the Tea Party movement and Occupy Wall Street because it shows that the American people still feel like their voices can be heard. But, what happens when the police intimidate too many protesters? That’s when countries fail. 

I’m only worried because primary care doctors are so overworked, so underpaid, and so few that they can’t organize themselves and muster up an influential voice with a say. What does that mean to healthcare in America? If primary care is a healthcare system’s foundation, will I have to write the book, “Why Healthcare Systems Fail.”

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