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The idea is to get more people to the doctor before they get really sick and wind up in the emergency room. But if we do that, we won’t have enough doctors to go around unless we figure out how to create or import more of them.

The way it works now is, if you are uninsured, you’re probably not going to the doctor for regular checkups. So those little health problems go unaddressed, eventually turning into big health problems, which wind up in the ER—an inefficient care delivery model.

ERs are expensive to run, and health problems such as diabetes and heart disease become more expensive to treat the longer they’re ignored. It’s a major reason insurance premiums keep going up—hospitals charging paying patients more to make up for all the nonpaying customers.

The necessity of getting more folks insured and paired with a primary care provider isn’t a new revelation, but progress is slow and hurricanes Katrina and Rita didn’t help. Nevertheless, the goal is to do much the same thing for low-income adults as Louisiana did for low-income children through the successful LaCHIP program. A plan to eventually cover adults up to 200% of the poverty level would result in about 275,000 more people with insurance who want doctor’s appointments.

The only problem, unless something changes, is there won’t be enough primary care physicians—especially family physicians—to handle the load. We’re already short, in fact. Look at Massachusetts, where mandatory health insurance went into effect last year. More than half that state’s estimated 600,000 uninsured suddenly had coverage. Family practitioners have been swamped, and wait times for appointments have turned epic.

Why so few family doctors? The pay doesn’t compare to other fields of medicine. Medicare, Medicaid and even private insurance reimburse family doctors much less compared to what specialists make—ironic, given the state’s stated intention of pushing primary care. Medicare is the federal program for the elderly. Medicaid, the program for poor and disabled people, is a combination of state and federal dollars.

Dr. John Fleming, a family practitioner and congressional candidate from Minden, says it’s not surprising that medical students staring at $100,000 or more in student loans skip family medicine for more lucrative specialties. Fleming says the health care system should be privatized to get Congress out of the business of regulating what doctors get paid.

He proposes that Medicare and Medicaid be incrementally administered under private insurance, with funding still coming from the government “to one degree or another.” Let competition work its magic, he says, and doctors will get paid what they should.

“Competition always works,” Fleming says. “That’s the reason why we’re a capitalist country. Ultimately the price is going to be dictated by the market; the only way to do that is get government out of the calculation.”

In addition to long-term, wholesale changes to health care, which Fleming says will take “real boldness” and on the part of political leaders, reimbursements to family physicians need to be raised right away, whether it’s through private or government insurance. Now the feds plan to cut Medicare—again—by 10% on July 1, with another 5% cut in Jan. 2009.

Dr. Paul Perkowski, a vascular surgeon, says it’s easy to accuse doctors of being greedy when they complain about falling reimbursements, though that’s misreading the situation.

“Our issue is not just getting paid more,” he says. “Our issue is access to care for the patient. We get paid less for just about very procedure and every patient we see than we did five to 10 years ago. You have to disperse that cost somehow.”

Patient access suffers, as doctors shave the time they spend with each patient in order to see more of them during the day. Physician offices lay off nurses and staff, and put off hiring more doctors and investing in equipment, Perkowski says.

Adding another 275,000 people to the primary care patient pool without addressing the shortage of family physicians is “a potential disaster,” he says.

Dr. Robert Chasuk, director of the family medicine residency program at Baton Rouge General Hospital, predicts “a time of crisis” before things change. “It will take a severe shortage to compel the powers that be to change the way health care is delivered,” he says.

Chasuk says state medical schools in New Orleans and Shreveport are producing a fraction of the family doctors they have the capacity for. So we’re increasingly reliant on MDs from foreign medical schools, who aren’t as likely to stick around. Our med schools should do more to attract students to family medicine and then hold that interest, Chasuk says.

A 2006 report by the Louisiana Interagency Task Force on the Future of Family Medicine illustrates the depth of the problem. The report classifies 97% of Louisiana parishes as “primary care health professional shortage areas.” Only a third of the state’s doctors practice any type of primary care medicine, which covers general practice, internal medicine, OB/GYN and pediatrics in addition to family practice.

About 70% of the family physicians who go through Baton Rouge General’s residency program, which started in 1994, end up practicing within three parishes of East Baton Rouge, Chasuk says. “Residents tend to stay where they’re trained,” he says. “If we can train them in Louisiana, they’ll stay.”

David Hood is senior health policy analyst for the Public Affairs Research Council of Louisiana and was the Department of Health and Hospitals secretary during Gov. Mike Foster’s administration. The state has suffered a shortage of primary care for “a good while,” he says. The hurricanes just made it worse. Adding another 275,000 to the insurance rolls will undoubtedly make it even worse. But that’s no reason to give up on a major overhaul of the state’s health care system—though Hood suspects it will be used as an excuse for inaction.

“I don’t think any of that is a good enough excuse to not move forward,” he says. “We’ve wasted entirely too much time already.”

The state should be willing to put up more money for Medicaid reimbursement payments—at least matching Medicare, which isn’t great but better than Medicaid, which Louisiana currently reimburses at 90% of Medicare. With the state’s $6.3 billion Medicaid program, lawmakers should be able to find extra money to compensate the kinds of doctors we need more of, Hood says, noting that a relatively small investment in primary care yields a large return.

“This is something we really need to get our minds wrapped around,” he says. “Sitting on the sidelines while everything goes to hell in a handbasket just isn’t going to work. There are a lot of potential solutions here and we need to work through them.”