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ANDREA SEABROOK, host:

It's All Things Considered from NPR News. I'm Andrea Seabrook. As the incoming administration looks for models in its quest to transform healthcare, a lot of heads turn toward Massachusetts. That state has dramatically rebuilt its health insurance system in the last few years.

The upside - many more people are getting insured. A downside - there aren't enough primary care doctors to meet the surging demand. Karen Brown is a Kaiser Foundation fellow at member station WSCR in Amherst, Massachusetts. Here's her report.

KAREN BROWN: Kamela Christara appears at the triage window in the emergency room at Cooley Dickinson Hospital in western Massachusetts.

Ms. KAMELA CHRISTARA: I passed out last week.

Unidentified Woman #1: So could you fill one of these out?

BROWN: The 47-year-old single mother has advanced Lyme disease, and she can't find a primary care doctor to oversee her care. She's called half a dozen practices in three towns, and none are accepting new patients. So when problems come up, even routine ones, she comes to the emergency room. Each time, she goes through her medical history with the intake nurse.

Ms. CHRISTARA: I have a lot of neurological problems.

Unidentified Woman #1: Have you ever had a stroke or anything?

Ms. CHRISTARA: Well...

Unidentified Woman #1: Or seizures?

Ms. CHRISTARA: If you see on the records, where I said here...

Unidentified Woman #1: OK.

Ms. CHRISTARA: I had been taking wrong combinations of medications that created two seizures and some small strokes.

BROWN: Christara is worried she'll keep getting sicker if no one doctor is tracking her health. Even her regular prescriptions come from the emergency department.

Ms. CHRISTARA: I should be on thyroid medication, but I haven't been able to get blood work because I don't have a primary care physician.

BROWN: At least Christara doesn't have to pay out of pocket for this ER visit. She has the state's Medicaid insurance, which was expanded under a landmark health reform law passed in 2006. It requires all Massachusetts residents to have health insurance, either through a state-subsidized plan, an employer, or privately-bought insurance. As a result, an estimated 440,000 more people have health coverage, and they all need a primary care doctor to get into the system.

Dr. JACQUELINE SPAIN (Medical Director, Holyoke Health Center): Well, I think it's great that people have insurance. I'm wondering where they're getting their care.

BROWN: Dr. Jacqueline Spain is medical director of the Holyoke Health Center, a busy clinic in a low-income community.

Unidentified Woman #2: Good morning, (unintelligible) medicine, may I help you? Can I have your date of birth?

BROWN: Since the reform law passed, the Holyoke Health Center has been inundated with calls from newly insured people seeking a doctor. More than 1,600 people are on its waiting list. Dr. Spain says it takes about four months to get a first appointment.

Dr. SPAIN: It's entirely reasonable for somebody who's now, you know, got insurance and maybe has a whole list of things that's worried them and troubled them, now they have insurance, and, of course, they expect that they should be able to go out in the market and get all that care. There just aren't enough of us to give it to them.

Dr. KATE ATKINSON (Family Doctor, Massachusetts): We get five or 10 calls a week, sometimes a day from patients who need a new doctor and literally, people crying and begging to come into the practice.

BROWN: Kate Atkinson is a family doctor in nearby Amherst. She's become a national activist for improvements in the primary care system.

Dr. ATKINSON: I've been very vocally saying that 18 primary care doctors in this area have left the practice of primary care in the past two years. Someone needs to ask why.

BROWN: For one, she says, money. Insurance companies, Medicaid and Medicare, pay less for primary care than for specialist visits. And no one pays for the time it takes to fill out paperwork or take surveys for the insurance company or write sick notes to employers.

Dr. ATKINSON: A urologist in one procedure makes more than I make in two days of seeing patients.

BROWN: Massachusetts doctor Dan Levy, who left primary care for medical administration, says that's only getting worse with universal health care, since newly insured patients tend to come with a pile of saved-up complaints.

Dr. DAN LEVY (Physician, Massachusetts): You have someone on your hands with five separate medical problems, 15 minutes to see them. If you spend the extra half hour, you don't get paid for it, so the pressure is to refer them to a subspecialist. It takes a lot of the pleasure and fun out of doing medicine.

BROWN: In a national study released this fall by the Physicians' Foundation, 80 percent of primary care doctors called the job unrewarding. Half of them plan to scale back or stop practicing within three years. At the same time, most medical students are choosing specialty tracks, like surgery or pediatrics.

The trend could raise the cost of health care. People without primary care doctors tend to rely more on emergency rooms and let small problems get bigger. Massachusetts recently passed legislation to make primary care more attractive through loan forgiveness, home-buying help, and better reimbursement. State Representative John Scibak says the viability of health reform is at stake.

State Representative JOHN SCIBAK (Democrat, Massachusetts): The worst thing that could happen in the legislature right now is inaction.

BROWN: It won't be easy to pay for change, especially in this budget climate. Still, John McDonough says that's no reason to give up on universal health care. He was one of the architects of Massachusetts health reform and is now an adviser to Senator Ted Kennedy.

Mr. JOHN MCDONOUGH (Adviser to Senator Ted Kennedy): What has happened is that Massachusetts health reform has put a spotlight on the workforce shortages that doesn't get meaningfully talked about in a broad public way in just about any other state.

BROWN: In other words, Massachusetts is merely the first to take on a problem the rest of the country will soon confront, especially if more people are given health insurance. For NPR News, I'm Karen Brown.

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