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I greatly appreciate the thoughtful and informative eLetters about my article. I know many people share the pessimism expressed by Drs. Saver and Antonucci about meaningful beneficial changes ever coming to primary care. The longstanding barriers and entrenched interests are formidable. But as Drs. Green and Fish articulate in their powerful letters, we can muster our resolve and faith in times of hardship and look for stars in the darkness of midnight to find a way forward and not succumb to defeatism. It has been said that hope and optimism are different concepts. Optimism is a judgment of what is likely to happen, and hope a conviction of what must happen. I remain hopeful if not always optimistic.
I appreciate Dr. Halloran's solidarity as a psychologist deeply involved in family medicine practice and education, and her note of hope.
Dr. Gill share's extremely important lessons from his deep experience in state level policy change on primary care spend in Delaware. Critically, he highlights the limitations of a state level policy that only affects about 10% of overall insurance payments and beneficiaries due to excluding Medicare and Medicaid and self-insured employer based plans. This is one reason that I propose a unified financing system for primary care so that an increase in primary care spend would apply to the entire health care budget and not just a small slice. In California, state Senator Scott Wiener has introduced SB770, instructing the state set a timeline for negotiation with the Federal Government to incorporate federal funding of Medicare and Medicaid into a state based single payer program for all Californians. Maryland is an example of a state that has obtained federal waivers to permit an all-payer model that is another approach to overcoming the limitations Dr Gill describes.
Sometimes it can feel like 2 steps forward, 1 step backwards (or 1.75 steps backwards). But I hope we can channel the energy of family physicians, other primary care workers, and patients and the public to keep marching forward, despite the obstacles in our way.