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Less staff, longer delays and fewer options: Rural America confronts a health care crisis

More than 40,000 graduating medical students learned Friday where they will spend the next three to seven years of their medical training.

With the United States grappling with a simultaneous shortage of primary care physicians and a rural health care crisis, many of the graduating students are set to enter the front lines of the country’s health care shortage.

At least 136 rural hospitals and health systems closed between 2010 and 2021, and over 40{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of rural hospitals operate with negative profit margins. Despite billions of dollars in investment in health care, hospitals throughout the United States face the possibility of shutting down.

“I would say it is probably the worst time for health care that we ever experienced,” Joanne Conroy, the chief executive officer and president of Dartmouth Health, told ABC News. She noted that increased costs, inflation, limited housing, and workforce shortages have made running rural hospitals more challenging.

Less staff, longer delays and fewer options: Rural America confronts a health care crisis — Duke students express joy on Match Day learning where they would spend the next three to seven years for their residency program.

Duke University School of Medicine

“We know what to do if we face another pandemic,” Conroy said. “The question is whether or not we have the financial resilience in order to survive it.”

Many hospitals that remain open have cut costs to survive, offering fewer services and beds.

In 2020, 47{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of rural community hospitals did not provide obstetric services, with 89 obstetric units closing between 2015 and 2019. Seven million women reside in counties with limited or no access to maternity care, impacting half a million newborns annually.

According to Conroy, patients can already feel the impact of the crisis, noting that some women in New Hampshire need to drive two hours to deliver their babies. Other effects include fewer available beds in emergency rooms, delays for elective surgery and longer wait times for prescriptions or ambulance pickups.

For new medical professionals entering their residency, especially those joining rural systems, the circumstances of the struggling health systems are out of their control.

PHOTO: Duke students express joy on Match Day learning where they would spend the next three to seven years for their residency program. — Duke students express joy on Match Day learning where they would spend the next three to seven years for their residency program.

Duke University School of Medicine

“It is not my job to fix all of the problems for an entire community, that’s impossible. When you feel like that’s your responsibility, burnout is basically inevitable,” said Katie Stevenson, a Tufts medical student. “When you feel like your goal is to do the best you can with the resources you have, you are able to right-size your expectations a bit.”

An increasing number of students are entering medical school programs that focus on rural medicine. In 2019, the Health Resources and Services Administration issued grants to create 32 newly accredited rural residency programs, supplementing the preexisting programs.

This year, Tufts School of Medicine will graduate its tenth class of students from its Maine Track MD program – a partnership with Maine Medical Center that allows students to pursue a community-based curriculum and gain financial incentives to encourage primary-care specialties.

STOCK PHOTO: A teacher gestures as she lectures a class of college students. — A teacher gestures as she lectures a class of college students.

STOCK PHOTO/Getty Images

Graduating roughly 40 students annually, 27{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of Maine Track students have been matched to programs in Maine and 47{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} have been matched into primary care programs, according to Dena Whitesell, an assistant dean for students at Tufts and psychiatrist at Maine Medical Center.

“We know that students and residents who live in an area [and] who train in an area are more likely to practice in that area in the future,” Whitesell said.

Liv Fauver, a Tufts student who matched with a University of Vermont residency program, grew up in rural New Hampshire and said she felt motivated to work in a similar community where she could positively impact the local residents.

“I think for me, my goal is to live and work in the community that I serve,” she said. “So I’m really in a place where I go home or go to the grocery store and see my patients all the time, because that’s the world that I live in and work in.”

While rural hospitals have closed in record numbers, PCPs – medical professionals who patients regularly use for checkups and other routine care – face additional challenges, especially in rural areas, according to experts.

Greg Sawin, a PCP who has practiced in Massachusetts and Maine as well as Duke University School of Medicine professor, said he worries that the goals of primary and long-term preventative care can sometimes be at odds with larger health care systems.

“We get paid to do things to people. We don’t get paid to keep populations healthy,” he said.

Moreover, he believes the costs associated with medical schools – including the high cost, the likelihood of incurring debt and substantially higher pay to pursue competitive specialties like orthopedic surgery or dermatology, for example – disincentivize primary care options like family or internal medicine.

“It can be very appealing to want to go into a specialty where you’re guaranteed to make more money and pay that debt off more easily,” Stevenson said.

Owen Foster lives in rural Vermont and has felt the impact of the decreased number of available PCPs, spending six months to book an appointment with a doctor. Living in a rural area, Foster shares his dilemma with millions of Americans in rural areas impacted by the shortage of PCPs.

“You need basic things at certain intervals in your life,” he told ABC News. “If you don’t have a primary care provider, you can’t get that and you can’t get the referrals you need, so it’s really, really difficult.”

What makes Foster’s experience unique is his position as the state of Vermont’s top health care regulator. As chair of Vermont’s Green Mountain Care Board, he oversees the quality and cost of the state’s health care system.

Learning about the shortage of primary-care physicians in Vermont, Foster decided to use the opportunity to find a PCP as a chance to examine the market as a “secret shopper.”

“What I found was I was completely incapable of getting a doctor,” he said. “I called eight places and the best I got was on an indefinite wait list, which never came to fruition.”

Rural areas comprise about two-thirds of the primary care health professional shortage areas nationwide, even though only 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of Americans live in rural areas.

The problem is also likely to worsen over time. Projections indicate that the United States will likely suffer a shortage of between 17,800 and 48,000 PCPs by 2034.

Moreover, health care professionals believe that the shortage of PCPs can make other elements of health care more expensive and worsen overall patient outcomes. Sawin gave the example of a person getting strep throat. Without a PCP, the person might go to a local hospital emergency room, which is significantly more expensive than other treatment options.

“In terms of mismatch of resources, you know, a kid with strep throat showing up in the ER is like cutting butter with a chainsaw,” Sawin said.

Foster added that primary care providers are “critical to controlling the costs of a health care system” due to their role in the early identification of issues, their ability to diagnose mental health issues, and their approach to preventative medicine.

According to Foster, PCPs in rural areas, however, struggle to find and retain staff, negotiate with insurance companies and prevent burnout. The shortage of PCPs, combined with the increased health care needs of the older population in rural areas, creates a concerning combination.

STOCK PHOTO: A group of medical students discussing some work while huddled around a whiteboard at the lab together. — A group of medical students discussing some work while huddled around a whiteboard at the lab together.

STOCK PHOTO/Getty Images

Despite these issues, Foster said he was optimistic about some approaches to make primary care more financially feasible, including adding a floor for PCP spending within health plans and government involvement in rate setting.

A new generation of students graduating from rural track programs also has the potential to reverse the tide of the PCP shortage in rural areas, with 571 additional primary care matches this year. Stevenson, for example, matched with the Swedish Cherry Hill rural program in Washington state.

“I think we have an opportunity in this country to do a much better job of taking care of our patients if we do a better job of funding primary care and preventative care and creating healthy environments,” Stevenson said.

Teen mental health is in crisis, study shows. What can parents do?

Results from a recent Centers for Disease Control and Prevention survey add to the evidence that teen mental health is in crisis, with particularly concerning numbers surrounding teen girls.

The survey found around 1 in 3 high school girls in the U.S. have seriously considered attempting suicide and more than half of teen girls, 57{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}, reported feeling “persistently sad or hopeless” — a record high.

By contrast, 14{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of high school boys told the 2021 survey that they had seriously considered attempting suicide, up from 13{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} in 2011.

Among LGBQ+ students, close to 70{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} said they experienced persistent feelings of sadness or hopelessness during the past year, more than 50{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} had poor mental health during the past 30 days and almost 25{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} attempted suicide during the past year.

Alyssa Mairanz, a licensed mental health counselor and owner of Empower Your Mind Therapy, says the numbers are distressing, yet unfortunately, she “wasn’t surprised.”

“There are a few things that teens nowadays deal with that older generations didn’t have to deal with,” Mairanz notes, including social media, which can lead to harmful comparisons and online bullying, as well as the impact of the COVID-19 pandemic on developing minds.

So what can parents do to make sure their teens are OK?

Know the line between normal and not

“There’s so many things that are typical with teens that aren’t necessarily cause for concern, like general moodiness (and) fighting with parents,” Mairanz says. “Parents don’t know when it’s cause for concern and what’s more normal, so I think understanding that line is super important.”

She says it may be a sign of something more serious if you see your teen…

is in intense, longer-lasting low moods
is becoming more isolated or withdrawn, including not wanting to socialize or see friends
is not wanting to get out of bed
is engaging in high risky behaviors, including physical aggression or intense substance use

Another sign that often goes under the radar? High perfectionism.

“A teen that’s really setting these very high, unrealistic standards for themselves in terms of anything — could be grades, friends, looks,” she says. “When it’s really that high, it’s definitely a warning sign. These can often lead to depression (and) suicidality.”

Discussing the results of the recent survey on CBS News “Prime Time,” Dr. Debra Houry, chief medical officer at the CDC, noted that changes in sleep and appetite can also be an indicator.

Listen and validate

“When parents are more validating to their child and focus on what they need versus what maybe the parent is assuming, teenagers tend to be much more open and willing to come to their parents when they’re struggling,” Mairanz says.

So, instead of opening a dialogue the intention to provide solutions, which may look like this:

Responding to an upset teenager with, “Oh it’s fine,” “It’s not such a big deal” or “It’s all going to be OK.”
Or saying, “Let’s talk about how we can study better” or “Let’s create more intense notes” when a child does poorly on a test.

Mairanz suggests listening and validating, instead.

“Parents don’t necessarily even realize how their response to their teenagers can have an impact. … But a lot of times, the children really just need the emotional support. Because when they hear a solution, they hear, ‘OK, I’m not doing enough,’ rather than, ‘OK, this is a struggle and it’s understandable that you’re upset.'”

Houry says being as “open and nonjudgmental as possible” can help a child feel more comfortable coming to their parent.

Keep an eye on social media usage

Parents should look out for a “real codependency” between their kid and their phones, which can look like being on social media and not taking breaks, Mairanz advises.

“Especially if it’s impacting their ability to function, go to school, do their homework, be with friends… it’s important to try to make sure teens get a break from all of that,” she says.

Don’t be a stranger to your child’s circles

It’s important not only to talk to your child, but to know your child’s friends and their friends’ parents, Houry says.

“That way you’re able to have an open communication with families around you, build that support system and have a good sense of where your child is and what they’re up to,” she explains.

Don’t ignore a child asking for help

If a child asks for professional help, don’t brush it off. Experts say that’s a sign to take action.

“Sometimes there’s still a stigma around therapy, especially with parents because (they) want their children to be OK and they take it very personally when we’re not,” Mairanz explains. “It’s unfortunately common for parents to be like, ‘You’re fine. This is just normal teenage stuff, you don’t need help.'”

If a child isn’t comfortable enough to ask for support, look out for signs they need professional help, including self-harm, increased substance use, withdrawing from school or a change in sociability.

Make sure you’re OK too

While it’s important to focus on the teen, Mairanz says it’s also crucial for parents to realize they need to focus on themselves.

“Whether it has to do with their own mental health issues or specifically around parenting, kids pick up a lot – so if a parent is really struggling, it’s important for them to deal with that,” she says. “Know that part of helping your teen is also helping yourself.”

If you or someone you know is in emotional distress or crisis, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988. You can also chat with the 988 Suicide & Crisis Lifeline here.

For more information about mental health care resources and support, The National Alliance on Mental Illness (NAMI) HelpLine can be reached Monday through Friday, 10 a.m.–10 p.m. ET, at 1-800-950-NAMI (6264) or email info@nami.org.

Inside America’s youth mental health crisis

Kids in the U.S. and around the world are in crisis.

More than 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of children with depression don’t get any mental health treatment, according to Mental Health America. Pair that statistic with the fact that about 80{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the United States has a severe shortage of child psychiatrists, and the picture becomes clear: there is a growing mental health crisis in the United States and beyond.

That’s why CBS News and local CBS-owned television stations spent more than six months exploring the sources of the problem, as well as solutions across the country that could address it. This is a collection of the reporting by CBS journalists, committed to the well-being of our kids.

Documenting kids’ personal struggles

“Bring darkness into the light,” said filmmaker Noemi Weis.

That’s the goal of her documentary, “Connecting the Dots,” which features young people from around the world candidly talking about their struggles with mental health and the need to be supported.

“We need to listen in a way that is with open eyes and with providing a safe space, providing no judgment,” Weis told CBS News. “As much as we believe that we are in a world where we are all connected, the disconnect is huge. The isolation, the loneliness needed to be addressed.”

CBS News licensed the documentary for an exclusive release nationwide on its streaming platforms Wednesday night. The film will be available to view on demand following the streaming event.

The filmmaker created facilitator guides, in partnership with UNICEF, for youth, parents, educators, mental health professionals, and others to watch the documentary and discuss it.

Seeking mental health help

If you or someone you know is in crisis, get help from the Suicide and Crisis Lifeline by calling or texting 988.

In addition, help is available from the National Alliance on Mental Illness, or NAMI. Call the NAMI Helpline at 800-950-6264 or text “HelpLine” to 62640. There are more than 600 local NAMI organizations and affiliates across the country, many of which offer free support and education programs.

What Dr. Simi tells us about Mexico’s healthcare crisis

ECATEPEC, Mexico —

He sports a bushy white mustache and a bit of a gut. He dances to reggaeton in cities and towns across Mexico. He has 2 million followers on TikTok and at concerts is routinely passed into the arms of pop stars. His face even adorns a mountainside.

He is Dr. Simi, the cartoon mascot of Farmacias Similares, Mexico’s largest drugstore chain, with more than 8,500 locations across the country. His ubiquity speaks to the company’s round-the-clock marketing strategy but also something darker: the failure of the Mexican government to deliver on its promise of healthcare for all.

Medicines are often in short supply in public clinics, where it can take weeks to get an appointment with a primary care doctor.

A woman with long dark hair sits at a computer terminal. On the desk are dolls of a man in a lab coat

Farmacias Similares helps fill the gap with cheap generics and $2 doctor visits. The chain says its clinics next to each location provided 136 million appointments last year.

Many pharmacies feature an employee in a Dr. Simi padded bodysuit waving to passersby and engaging in antics such as challenging the cow mascot of Mexico’s Alpura milk brand to a dance-off.

A group of people dressed as mustachioed characters in different costumes pose for a photo

At the company’s headquarters in Mexico City, a mural shows Dr. Simi with a raised arm declaring: “To serve God and the people!”

Dozens of employees there answer calls to the “Simitel” hotline that provides free access to doctors, nutritionists and psychologists — and for those who press “1” to Dr. Simi himself.

Operators who have perfected the mascot’s cheerful nasal voice answer several hundred calls a day by reading a joke from a binder or simply offering a friendly ear. Alberto González, who has played Dr. Simi for nearly 17 years, cherishes callers such as 27-year-old Luis, who dialed in more than a decade ago to talk about his parents’ divorce and still phones every few weeks.

A man sits at a workstation. Behind him is a poster of a mustachioed character and the words Bienvenidos a Similandia

The operators never break character.

“Hello, hello! How are you?” goes the script. “You’re talking to Dr. Simi. Who is calling me?”

In 1997, Mexico began requiring drugs to be labeled by their active ingredient rather than a name brand. The idea was to increase confidence in medications and open up the market to generic drugs.

The new rules were a business opportunity for Victor González Torres, whose family company had long manufactured drugs for the government health system.

That year, he founded Farmacias Similares. The name is a reference to generics, which were advertised with the slogan “The same, but cheaper.”

Promising “up to 75{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} in savings,” the company launched a marketing campaign that presented the chain as coming to the rescue of poor Mexicans and pushed back against transnational pharmaceutical companies that disparaged generics.

A mural along a set of stairs depicts a man holding a note near other people

González wanted a mascot with the right combination of goofiness and wisdom. After rejecting several ideas from an advertising company, his team found an artist who designed the winner: a simple black-and-white drawing of a doctor joyfully holding up his arms. The inspiration came from a famous movie character from the 1940s, Don Susanito Peñafiel y Somellera.

Dr. Simi first appeared in newspaper advertisements. He then took shape as an animated cartoon and a puppet on television, happily explaining why the public should trust generics.

A woman holds a blue sign outside a storefront, near a passerby

Before long, Dr. Simis were dancing on the sidewalks. The company created a comic called “The adventures of Dr. Simi” and a band of “Simichicas,” well-known actresses and models who traveled with the founder and promoted new products such as the “Simicondom.” “SimiInsurance” offered medical treatment for a premium.

One of the chain’s key moves was to open clinics — which are operated by a sister company — alongside its pharmacies.

The cheap clinics made healthcare more accessible to the tens of millions of street vendors, taxi drivers and others working in the country’s informal sector. It was a population excluded from public health insurance systems — in apparent breach of the Mexican Constitution, which was modified in 1983 to make healthcare a universal right.

A masked man in a white coat holds a syringe near a masked woman seated on an examination table

Like some political parties, the chain also handed out free rice and offered social assistance in poor neighborhoods.

Its populist strategy worked. By 2003, Farmacias Similares had roughly 1,000 locations and was looking abroad.

The government healthcare system expanded substantially the next year under a new program known as Seguro Popular that offered health insurance to workers in the informal economy. But that didn’t appear to stall the growth of Farmacias Similares. Catering to hourly workers who couldn’t afford to take time off to travel to public health centers, the chain placed its pharmacies on busy streets, often near bus stops, and grew rapidly by offering franchises.

By operating on a massive scale and manufacturing many of its own drugs, the company cut costs further and passed on the savings to customers.

“Victor González Torres and Farmacias Similares executed a tremendously effective strategy,” said Michael Chu, a Harvard business professor who has studied the chain.

González’s profile was growing too. Long encouraging people to call him Dr. Simi, he did not hide his desire for prestige, declaring once that he wanted to be remembered as a revolutionary like Che Guevara.

He butted heads with officials in the public health system after alleging corruption in its drug-purchasing practices and campaigned for president as a write-in candidate in the 2006 election.

“Poor people can have power in a country where there are so many,” he said in an interview at the time. “They can choose a president.”

The company has also waded through a fair share of controversy. González’s brother was the founder of Mexico’s Ecological Green Party, which in 2010 faced accusations of conflict of interest after sponsoring legislation to provide people with vouchers for medications in private pharmacies. The media dubbed it the “Simi law.”

The law failed to pass, but Farmacias Similares continue to grow amid the government’s faltering attempts to improve the public health system.

More than a quarter of the population lacked access to care in 2020, according to the government’s most recent estimate.

That same year, President Andrés Manuel López Obrador replaced Seguro Popular with a new program he promised would reduce corruption. But it has been beset by medicine shortages that experts attribute to bureaucracy and the COVID-19 pandemic. The government is currently transitioning to yet another program.

As a result, clinics next to private drugstores have been booming and are now thought to serve roughly a fifth of the population. Farmacias Similares opens nearly two new locations a day on average.

Carmen Maldonado, who owns a shop that sells artisanal honey and cheeses, recently dropped by Farmacias Similares’ first store — located in Mexico City’s Portales neighborhood — to buy cold medication and antibiotic injections, which a doctor administered at the clinic next door. A sign outside advertised birth control, oxygen and blood sugar readings, stitches and ear cleanings.

Maldonado could opt to use the public system, but the clinic is near her home and she’s been seeing this doctor for 20 years.

“He’s like the family doctor,” she said.

In November 2021, a 19-year-old high school student named Avril Christelle Vega Martinez was on her way to a concert in Mexico City when she stepped into a Farmacias Similares to pick up some hand sanitizer.

She had also been looking for a Dr. Simi doll, so she was happy to find the store had one left in stock. The dolls come in different guises — including boxer, mariachi and fireman — but the one she bought was the classic version: Dr. Simi in his lab coat.

Plush dolls sit on a bookcase in the shape of the letters C and S, next to a larger version of the mustachioed character

Vega had taken the doll out of her backpack at the concert — Norwegian electro-pop singer Aurora Aksnes — when an idea popped into her head.

“I suddenly thought of the idea of maybe giving it as a present to Aurora,” she recalled. “Dr. Simi is a symbol of Mexican culture. We grew up seeing Dr. Simis dancing everywhere.”

And so she passed the doll up through the crowd until someone flung it onto the stage. Aurora picked up Dr. Simi and hugged him to her chest.

Captured on video, the incident went viral on social media, and it wasn’t long before Dr. Simi dolls were routinely being thrown onstage at concerts of pop stars including Dua Lipa and Rosalía. Joining in on the fun, a former chief justice of Mexico’s Supreme Court “ruled” on TikTok that doing so isn’t a crime.

The publicity was good news for Farmacias Similares. Dolls were selling so fast that the company boosted monthly production to 40,000 from 12,000. When one was left at a memorial for Queen Elizabeth II in Edinburgh last year, Mexican media outlets thought it newsworthy enough to cover.

The company carefully guards Dr. Simi’s image. The more than 1,000 staffers who wear Dr. Simi bodysuits are forbidden to speak to the public while in costume in order to preserve the character’s identity. One benefit of the job: lessons in dancing salsa, cumbia and the Simi pasito.

A communications team works a night shift to produce seven television shows a week, bringing in specialists to discuss anxiety and stress, as well as staffers from different areas to explain their jobs. Employees keep a close eye on social media, tracking down for an interview members of the public who have helped Dr. Simi go viral.

The company also promotes its brand through what Victor González Herrera, the son of the founder, called “conscious capitalism” — funding natural disaster relief, tree planting and food assistance for the hungry.

In December, the company raffled 25 cars to customers to mark its 25th anniversary. Before the winners collected their new car keys, pharmacy employees launched into the corporate anthem:

We have the courage
Dr. Simi has the heart
What we offer
We do with love

With pharmacies in all of Mexico’s 32 states and more than 400 in Chile, the company aims to reach its target of 10,000 pharmacies in the next five years and ultimately become the largest chain in the world.

“Simi has simply become necessary,” said Victor González Herrera, who recently took over as head of an umbrella group that includes the pharmacies and the clinics.

Health experts have warned that while the pharmacy clinics can treat immediate illness, they are not ideal for chronic conditions.

“Can it be a business that does good? Without a doubt,” said Dr. Andrés Castañeda, who coordinates health issues for Nosotrxs, a Mexican organization that promotes citizen participation in public policies. “But the health system can’t leave things 100{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} in the hands of clinics adjacent to pharmacies.”

One problem is that the care may not be consistent, because the doctors tend to come and go.

But Cori Hayden, an anthropologist at UC Berkeley who recently published a book on Farmacias Similares called “The Spectacular Generic,” said that many people have resigned themselves to “something is better than nothing” when the state fails to provide healthcare.

“It’s a force. It’s wild,” she said of the chain. “It’s totally wild.”

But its true power remains something of a mystery, because Farmacias Similares keeps its sales figures private.

“It’s a gray area,” said Jorge Perichart, director of the National Assn. of Sales Executives of the Pharmaceutical Industry. “We don’t know what we’re competing against.”

Four people look out of an upstairs opening in their home, which painted in blue with black stripes

About 30 miles north of the center of Mexico City, in a mountainside community in the municipality of Ecatepec, the homes have bare concrete floors and tin roofs. Access to running water is a luxury.

For Farmacias Similares, the Lomas de San Carlos neighborhood was not just a symbol of neglect: It was a canvas.

Last year, the company sent in representatives offering residents food assistance and free house painting. Then painters got to work on 305 houses.

The result was an advertisement for Farmacias Similares visible from the nearby highway.

White houses make up a man’s bushy mustache, pink houses his tongue, and black-striped houses the three wiry hairs on each side of his head.

It was, of course, Dr. Simi.

A view of homes in a neighborhood painted to depict the likeness of a cartoon character with a white mustache

The company — which also remodeled the community center, built a vegetable garden and opened two new pharmacies nearby — dubbed Lomas de San Carlos “Simi Neighborhood.” Reporters rushed to cover the story.

“No one has ever paid this much attention to us,” said Hortencia Olivares Ramos, whose home was painted blue — the background of the mural.

At the mountain’s peak, Eva Ojeda López lives with her husband and four children in a house painted to match the hairs on Dr. Simi’s balding head.

The stay-at-home mother buys her hypertension pills at Farmacias Similares when the public pharmacies run out and frequents the company’s clinics for basic ailments such as colds.

Ojeda swore that the arugula from the new community garden lowered her cholesterol levels. One of her daughters read the book that Farmacias Similares gifted the family: the founder’s autobiography, “My Life Is a Struggle.”

Another daughter Johana, 18, joked about how some of her neighbors lived by Simi’s tongue or his eyes.

“We consider ourselves a part of Dr. Simi,” she said.

Patient Burnout Is a Simmering Public Health Crisis

You haven’t been feeling well lately. You’re more tired than usual, a bit sluggish. You wonder if there’s something wrong with your diet. Or maybe you’re anemic? You call your primary-care doctor’s office to schedule an appointment. They inform you the next available appointment is in three weeks.

So, you wait.

And then you wait some more.

And then, when you arrive on the day of your appointment, you wait even more.

You fill out the mountain of required paperwork, but the doctor still isn’t ready to see you. You flip through a magazine for a while, then scroll through your phone until you’re finally called. You wait a little longer in a scratchy paper gown, then talk to your physician—if you can call it talking, since she’s mostly staring at a computer screen—for all of 10 minutes before you’re back out in the lobby with a lab order to have your blood tested.

Then you call to set up your blood test, and the waiting process starts over.

A few weeks after you get your results, a bill arrives in the mail. You’re charged hundreds of dollars for the blood work. The appointment was over in minutes, but your bank account will feel the effects for a long time.

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Going to the doctor may never be a fun experience, but surely it can be better than it is right now. In 2019, even before the COVID-19 pandemic rocked the foundations of health care, an Ipsos survey found that 43{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of Americans were unsatisfied with their medical system, far more than the 22{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of people in the U.K. and 26{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of people in Canada who were unsatisfied with theirs. By 2022, three years into the pandemic, just 12{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of U.S. adults said health care was handled “extremely” or “very” well in the U.S., according to a poll from the Associated Press–NORC Center for Public Affairs Research.

Americans pay a premium for the care they rate so poorly. The U.S. spends more per capita on health care than any other developed country in the world but has subpar health outcomes. Average life expectancy is lower in the U.S. than in other wealthy nations, and about 60{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of U.S. adults have a chronic disease. About 10{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of the population doesn’t have health insurance.

And the customer service sucks. U.S. patients are tired of waiting weeks or months for appointments that are over in minutes. They’re tired of high prices and surprise bills. They’re tired of providers who treat them like electronic health record entries, rather than people.

That could dissuade them from getting medical care at all—and if that happens, America may get a whole lot sicker than it already is. Patients are, in a phrase, burned out.

Primary care is supposed to be the bedrock of the U.S. medical system. In theory, patients get annual physicals so doctors can assess their overall health and detect any red flags (or refer them to specialists who can) before those warning signs become full-blown chronic disease. While experts debate whether everyone needs a checkup each year, studies show that on balance, patients who regularly see a physician tend to be healthier and live longer than those who don’t.

Yet about a quarter of American adults don’t have a primary-care provider, and, as of 2021, almost 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} hadn’t seen any doctor during the past year. There are many barriers: it can take weeks to get an appointment, particularly in more rural areas where fewer doctors practice, and visits can be costly even for people with insurance. Research shows that during the past year, financial strain caused about 40{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of U.S. adults to delay or go without medical care.

Plus, people just don’t like going. A third of participants in one 2015 study said they had avoided going to the doctor because they found it unpleasant, citing factors like rude or inattentive providers, long wait times, and difficulty finding a convenient appointment. Many people also skipped appointments during the COVID-19 pandemic, largely because of office closures and fears of the virus—but one study found that people were more likely to forgo doctor’s visits during the pandemic if they’d had previous poor experiences with health care. People of color, women, and people who are overweight frequently report feeling mistreated by their doctors.

Jen Russon, a 48-year-old English teacher and mother of two from Florida, says she can’t remember a single positive experience she’s had with a doctor. She struggles to square the $400 her family pays in monthly insurance costs with what she characterizes as a rushed and underwhelming care experience that pales in comparison with the attention her pets get at the veterinarian. “I wish we could see our vet instead, because they really spend a lot of time” with their patients, she says.

Part of the problem may go back to the way doctors are trained, says Jennifer Taber, an associate professor of psychological sciences at Kent State University and a co-author of the 2015 study on doctor avoidance. U.S. medical schools do an excellent job of teaching students how to practice medicine. But, she argues, they aren’t always as good at preparing students to be doctors, with all the interpersonal complexity that entails. “Patients won’t necessarily want to go back to doctors they don’t like,” she says. Even small gestures, like making eye contact with or leaning toward a patient as they speak, can help build a strong rapport, Taber says.

The pandemic certainly hasn’t improved bedside manner. It’s pushed nearly every element of medical care to the brink and prompted some providers to leave the profession entirely, worsening existing personnel shortages and contributing to an epidemic of physician burnout. According to one recent survey, 30{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of U.S. physicians said they felt burned out in late 2022, and about as many said they’d considered leaving the profession in the previous six months.

Physician burnout only adds to patient burnout, says Dr. Bengt Arnetz, a professor at the Michigan State University College of Human Medicine who researches how to improve primary care. “Providers feel stressed, burned out, less empathetic. A lot of times they don’t engage the patient, and the patient wants to be engaged,” Arnetz says.

But these problems didn’t start with the pandemic, says Lori Knutson, executive director of the Whole Health Institute, a nonprofit focused on improving health care delivery. “We should all be honest,” she says, “about the fact that health care has been slowly imploding for a period of time.”

It’s impossible to explain problems with U.S. health care without talking about insurance. U.S. patients pay more out of pocket for health care than people in other wealthy, developed countries, most of which offer some form of universal health coverage.

The insurance system is also endlessly confusing, says Dr. Ateev Mehrotra, a professor of health care policy at Harvard Medical School. Doctors may not know how much the tests they’re recommending cost, particularly when every patient has a different type and level of coverage, so surprise bills are common—and so hard to understand that patients often have to spend hours on the phone seeking clarity from their insurance providers. One 2020 study estimated that dealing with insurance companies costs the U.S. more than $20 billion annually in lost productivity.

How doctors get paid affects the patient experience too. Many health systems pay physicians based on how many appointments and procedures they squeeze in, which rewards lightning-fast visits over those that are “about the whole person and not just what’s wrong with them,” Knutson says. This system can also incentivize doctors to recommend tests and procedures that aren’t strictly necessary, which leads to extra costs and hassle for patients and added strain on the health care system.

Here, too, insurance is part of the problem. Doctors in primary care or family medicine often make significantly less than specialists, in part because their services are reimbursed at lower rates. That dissuades some medical-school graduates—particularly those saddled with debts—from entering general medicine, which contributes to shortages in the medical fields patients are most likely to need on a regular basis. When there aren’t enough doctors to go around, appointments get scarcer and physicians become overworked, rushing from appointment to appointment and drowning in paperwork.

Some simple solutions exist. In a study published in 2020, Arnetz and his colleagues analyzed what happened when one small medical clinic made minor tweaks to its operations, such as reassigning some of the main provider’s administrative duties to nurses or medical assistants and adding short team meetings to delegate tasks for the day. After two weeks, the clinic scored higher than a comparison clinic on measures of efficiency, contributing to better patient and provider satisfaction.

Traditional medical offices could also take cues from the services patients are increasingly gravitating toward, says Pearl McElfish, who researches health services at the University of Arkansas for Medical Sciences. Patients who can afford it are flocking to startups offering perks like same-day appointments and flat-rate monthly memberships. And one 2018 study co-authored by Mehrotra found that visits to urgent-care clinics, where patients can walk in instead of waiting for weeks, increased by more than 100{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} from 2008 to 2015 among privately insured U.S. adults. (During roughly the same period, primary-care visits dropped 24{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f}.) During the pandemic, urgent-care centers only became more popular—as did telehealth.

“Currently [the traditional system] isn’t meeting the needs of many patients,” Mehrotra says. “Patients are voting with their feet and going to these other care sites.”

The trouble with convenience-first medical care, however, is that it’s often issue-specific. If you go in to get a flu shot, you’ll get that vaccine and then be on your way. The clinician is unlikely to make sure you’re up to date on your other shots or perform recommended screenings—the kind of preventive care that can fend off bigger issues down the line. On the other hand, these newer options can “put pressure on existing providers to be a bit more patient-centric,” Mehrotra says.

Traditional medical offices could make some changes right away, without waiting for big structural overhauls, he says. They could offer “walk-in only” hours to treat people without appointments, text patients when the doctor is ready to see them, and include clear explanations on bills so patients understand what they’re paying for. Even small shifts like these could make significant differences to patients.

The stakes are high. Ashley, who is 35 and asked to use only her first name to protect her privacy, has a gene mutation that heightens her risk of breast cancer and is supposed to get an annual mammogram and two ultrasounds per year. But she has to move frequently for her job in academia and hasn’t had her tests done in four years because she got so fed up with the arduous process of finding new doctors, transferring medical records, and dealing with insurance every time she moves. “The barriers were enough that I just kept putting it off,” she says.

Burned-out patients may retreat from the institutions that made them feel that way. Ashley says she’s considering a preventive double mastectomy—a surgery she may have needed anyway because of her genetic predisposition, but one made more appealing by her desire to stop dealing with “pain in the butt” medical appointments. Russon, from Florida, says she’s felt tempted to cancel her family’s insurance and go to the doctor only when absolutely necessary, though she’s never acted on the urge. Other patients, however, may walk away from the health care system entirely. It may not be the wisest or healthiest response, but it’s a human one.

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Write to Jamie Ducharme at jamie.ducharme@time.com.

Britain’s NHS was once idolized. Now its worst-ever crisis is fueling a boom in private health care

London
CNN
—

Tens of thousands of nurses and nearly 12,000 ambulance workers went on strike Monday over pay and working conditions in the biggest walkout in the 75-year history of Britain’s National Health Service (NHS).

Escalating industrial action comes after years of falling wages, stretched budgets and staff shortages that have left the NHS in a state of crisis, with waiting times for treatment at a record high. At the same time, an aging population needs its services more than ever.

That unhappy mix is fueling a boom in demand for private health care from a much broader swathe of the UK population than ever before — a fundamental shift for a nation with one of the world’s best-known universal health systems.

“Our providers are telling us that people are going private, many for the first time, and the key factor driving that is the challenge in accessing NHS care,” said David Furness, policy director at the Independent Healthcare Providers Network, an industry body for private healthcare companies.

Nurses of the University College Hospital protest in London on Monday, February 6, 2023.

At the end of November, a record 7.2 million patients in England were waiting for non-urgent medical treatment on the NHS, known as “elective” care. This spans diagnostic tests and scans, procedures such as hip and knee replacements, but also cardiac surgery, cancer treatment and neurosurgery.

More than half of those on the list had been waiting up to 18 weeks and about 400,000 patients had been waiting more than a year, according to data from NHS England.

To avoid joining a waiting list, more and more people are paying for their own private medical care or taking out health insurance.

In the second quarter of 2022, the number of patients paying directly for private hospital care increased 34{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} compared with the same period in 2019 to reach 67,000, according to the Private Healthcare Information Network, which collects data on UK private healthcare.

The figures revealed a 184{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} jump in the number of people paying privately for hip replacements over that period, a 153{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} increase in self-pay for knee replacements and a 42{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} rise in private cataract surgery.

To keep up with growing demand for their services, private health care providers are expanding at a rapid clip.

US group Cleveland Clinic plans to open its third UK facility in London later this year, adding to the 184-bed hospital and the six-floor clinic it opened in the capital city in 2021 and 2022 respectively.

HCA Healthcare

(HCA), another American group, which has over 30 facilities in London and Manchester, will be opening a £100 million ($120 million) private hospital in Birmingham — the second biggest UK city — later this year.

London Bridge Hospital, one of the UK's largest private hospitals operated by HCA Healthcare.

And Spire Healthcare, one of the largest private hospital groups in the United Kingdom, is adding new clinics, theaters and beds around the country as it races to keep up with demand.

CEO Justin Ash estimates that the market for private health care in the United Kingdom has doubled since before the pandemic to 15 million people.

“Our biggest single challenge is how do we treat the numbers of patients coming towards us,” he told CNN.

The group plans to develop two new clinics in 2023, which are quicker to build than hospitals and are designed for procedures that don’t require overnight stays — for example, those in ophthalmology, gynecology and dermatology.

Spire is also pushing into primary care services, citing demand for face-to-face appointments with general practitioners. In December, it acquired The Doctors Clinic Group, a network of 22 private GP clinics with a strong presence in central London.

Ash said that appetite for private health care spans a much broader set of ages and incomes than in the past.

“This is not the super-rich. This is ordinary people who are choosing to go private, and that is a shift,” he said.

One such patient is Emma Freeth, a website administrator. She decided to take out private medical insurance after waiting nine months to see a specialist on the NHS.

“That’s what really triggered it: the idea that I just want to be able to get the help when I need it, rather than having to wait and wait and wait,” she told CNN. “If I was in pain or discomfort this would be a real problem,” she said of her thoughts at the time.

In November, Freeth, 58, and her 55-year-old husband Peter, a photographer, took out medical insurance in their personal capacity for the first time in their lives.

Their story is mirrored in data from health insurers. Bupa added 150,000 new UK health insurance customers in 2022, while rival VitalityHealth has seen a 20{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} rise in customers over the past year to more than 900,000.

“We expect the growth we have seen in health insurance uptake to continue in 2023,” said Neville Koopowitz, CEO of Vitality UK.

“This is because people are undoubtedly turning to private healthcare to ensure they have access to high-quality care, quickly, if they were to get ill,” he added.

Nursing staff and supporters march from University College Hospital to Downing Street on January 18, 2023 in London, England.

The Freeths, who are self-employed, said minimizing time off work with ill health was a major factor in their decision making, particularly given long wait times for appointments on the NHS.

According to the Office for National Statistics, record numbers of Brits are leaving the workforce due to long-term sickness, a problem it partly ascribes to long wait times for NHS treatment.

This is an issue of growing concern to employers. Recent polling by Savanta of more than 1,000 businesses on behalf of the Independent Healthcare Providers Network found that over half are worried that rising NHS waiting times may result in employees taking long absences or permanently leaving work due to sickness.

And one in five said they were considering offering private medical insurance to their employees in the coming year.

With the NHS estimating that it will take years for wait times to fall, the demand for private health care in Britain is set to keep growing.

Longer-term, there are questions about whether the NHS is sustainable in its current form, offering comprehensive free health care to all funded purely by taxes, particularly against the backdrop of an aging population and strained government finances.

The NHS is already the largest single item of public expenditure in Britain, according to the Office for Budget Responsibility, with ONS figures showing that healthcare spending amounts to around 12{bf0515afdcaddba073662ceb89fbb62b6b1bf123143c0e06b788e1946e8c353f} of GDP.

Some experts worry that moving away from a universal NHS would lead to a two-tier health system where people with means pay for private care, enabling them to go back to work and resume normal life more quickly than those who are less well-off and forced to rely on constrained public services.

“The risk is less a sudden privatization and more an emergence of something resembling the English education system — where the very best education is so often conditional on ability to pay,” researchers at the Institute for Public Policy Research, a think tank, wrote in a report last year.

“If this were to become the new normal… it would worsen overall health and widen inequality,” they added.

But Ash of Spire Healthcare has a less dystopian view of the future. “We’ve clearly moved into a world in which we’re all NHS patients but have episodes of private care,” he said.

That’s “a million miles from a US system,” he added. There is no universal health care in America and most people have private health insurance because health care is very expensive.

“There is huge commitment to the NHS. You cannot underestimate that,” Ash said.

Tag: Crisis