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Better Medicine

Atul Gawande, in his piece on the advantages of Costa Rica’s approach to health care, writes that what set the country apart wasn’t “simply the amount it spent on health care. It was how the money was spent: targeting the most readily preventable kinds of death and disability” (“The Costa Rica Model,” August 30th). As he observes, the medical system in the United States is much more reactive, and less focussed on community care. Limited access to primary care is perhaps the weakest link in our system, and it is largely due to the U.S. establishment’s emphasis on curing disease rather than on ministering to patients’ over-all health. This bias is also reflected in medical schools, which tend to push students toward specialties rather than toward primary care.

One way to address the deficits in primary care in the U.S. is to recruit medical students from among those mid-level practitioners—such as physician assistants and nurse practitioners—who are already delivering a great deal of this care. Currently, many of them are limited in their geographic mobility and the development of their own practices. Medical schools could design inexpensive two-year programs, tailored to qualified mid-level professionals, that would graduate primary-care doctors who could then practice in underserved areas. These programs would benefit not just those seeking an alternative pathway in the field but patients as well.

The financial foundation of any universal health-care program depends on a healthy population, which requires the early detection and intervention that are the special province of primary-care providers. Only once primary care for all is secured should a widespread focus on specialized care follow.

Ken Miller McKinleyville, Calif.

Gawande’s marvellous article about Costa Rica’s health-care system reinforces the idea that we in the U.S. need to change our health-care-reform focus from maintaining individual insurance coverage to addressing the underlying issues that make care expensive and unavailable to many. Between 2003 and 2006, I wrote two universal-health-insurance plans for California (S.B. 921 and S.B. 840). It became clear that the state had unresolved system-wide problems, such as a lack of management of capital investment, a separation between the public-health and medical-health establishments, care-quality weaknesses, poor use of purchasing power, excessive administrative expenditures, and data-access challenges—all of which raised costs, kept universal care unaffordable, and prevented coördinated approaches to patient health. I believe that studying—and then managing—these foundational problems will be as positive for our health-care system as Costa Rica’s reforms were for its own, and will bring us one step closer to creating a national health plan.

Judy Spelman Point Reyes Station, Calif.

Gawande shows how a small country such as Costa Rica can come to have some of the healthiest people on earth. One additional reason that Costa Ricans have been able to devote so much time and so many resources to developing their public-health system is that the country abolished its military in 1948. The end of the armed services allowed for a greater financial and cultural focus on health and education, resulting in a well-educated and long-lived population. There’s a lesson in this for politicians everywhere—devoting fewer resources to the military can lead to gains in the lives of a country’s people.

Joan Sturmthal Hallowell, Maine

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