Right at the moment, I don't need a pediatric urologist

But if I did, I could probably get an appointment tomorrow. However, last time I made an appointment for a routine visit with my primary care doc, I had to wait four months. NEJM's most excellent national correspondent John Iglehart discusses the problem of the primary care physician workforce, particularly in light of the promise that 95% of the population will have health insurance by 2014. As Iglehart puts it, "[M]andated coverage is only one of many challenges facing Democrats as they implement the most sweeping piece of social legislation since the enactment of Medicare and Medicaid. Another challenge that has attracted far less attention is whether newly insured individuals will actually have access to health care once they become insured."

Which means, if I have to wait four months now, I might have to wait eight months in 2014 -- if I can find a physician who will take me on at all. Iglehart's piece is fairly wonky so if you are prone to eyeball glazing, I'll just give you the bad news quickly. The Council on Graduate Medical Education says we need to increase the primary care workforce from the current 32% of docs to at least 40%. But it isn't happening: only about 17% of new medical residents appear to be headed toward primary care practice, in other words the situation is just going to get worse.

The health reform legislation takes only baby steps toward fixing this problem, which will accomplish little or nothing. Ultimately, it comes down to income, working conditions, and prestige, and specialists get the better of all three right now. As we know, many of these highly paid specialists don't like health care reform because they figure that eventually, it will force policy makers to deal with this problem and reduce the disparity in reimbursement rates. It doesn't help that some part of what they do, and bill for big time, isn't actually worth it, and payment reform might catch up to that problem as well.

But universal -- okay, near universal -- coverage won't be real unless we fix the crisis in primary care.