Medicine’s frontline of defense — the primary care physicians, the family doctors, if you will — is crumbling. And no national health-care reform plan is likely to succeed unless that critical problem is solved.

The issues of access and affordability are almost beside the point without addressing the shortage of primary care physicians. In his series "The Doctor Is Out," Lee Bowman of Scripps Howard News Service found that as many as one in five Americans does not have a family doctor. And this translates directly to higher rates of illness and death and higher costs.

Bowman, with SHNS computer-assisted reporting specialist Thomas Hargrove, surveyed databases and found that counties with more primary care physicians had significantly lower death rates than those with fewer family doctors and they also had lower death rates from detectable and preventable diseases like heart disease and colon cancer. For hypertension — elevated blood pressure that is treatable — the difference in death rates was 32 percent.

In a well-ordered medical system — which, after all, is what reform is all about — the family doctor would act as a quarterback, directing a team of nurses, nurse practitioners and technicians and referring patients to specialists as needed.

The government says there are 326,000 family doctors in the nation but not all of them provide primary care. By one measure that assumes the doctors are putting in brutal hours with a full load of patients, the country is short 60,000 to 80,000 primary care doctors.

That situation is about to get markedly worse and the best health insurance in the world is of no help if there aren’t frontline doctors to accept it. One survey found almost half of all primary care doctors say they plan to retire or curtail their practices in the next three years. And their replacements are not in the pipeline: Another recent survey found that only about 7 percent of medical students said they planned to pursue family care and only 2 percent of med school grads trained for internal medicine — the source of most family doctors — planned to enter primary care.

One reason is the pay — $150,000 a year or less, half as much as specialists are paid and a disincentive to medical students who graduate with an average debt of $140,000. Medicare, Medicaid and private insurance generally don’t pay for a family doctor to quarterback his patients’ medical care or for single visits that deal with multiple medical issues.

The alternative shaping up is a patchwork of emergency room visits, walk-in clinics, hoping to luck into a doctor who is accepting new patients or simply forgoing seeing a doctor, resulting in higher costs long term.

If, as is generally agreed, our health-care system is broken, primary care is the place to start fixing it.

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