Despite all the campaign chatter about reducing health care costs by sending folks to the doctor more often for preventive check-ups, mammograms, and prostate screenings, there has been remarkably little said about who will actually do the work of primary care medicine. That’s a shame, because mounting evidence shows that the U.S. faces a severe shortage of the primary care doctors who have historically provided this kind of care, and can do it cost-effectively and efficiently. The American College of Physicians tells us that “primary care is on the verge of collapse,” mostly because of a screwed-up reimbursement system that rewards high-priced specialists.

Although the public demand for general internists is expected to increase by 38 percent from 2000 to 2020, fewer and fewer young doctors are choosing to go into primary care. In 2003, only 27 percent of third-year internal medicine residents said they planned to practice that kind of medicine, compared to 54 percent in 1998. Many existing primary care doctors will either retire within the next ten years, or are looking for an exit strategy because the job has become too onerous, a point made in a recent New York Times essay by Sandeep Jauhar, M.D.

These extremely scary numbers are a discordant note in the chorus of politicians singing the same superficial song: “cover more people, bring on the check-ups, and health care will cost soooo much less.” A reader of this blog, D.E. Peterson, M.D., wrote to me about a former patient who was admitted to the hospital after a heart attack. His cardiologist had to consult several sub-specialists to manage his multiple illnesses, a regimen more appropriate to the training and expertise of a generalist. After the patient was dismissed, no one took charge of his care, which resulted in drug interactions, communication confusion, and soaring costs. Chaotic care like this happens every day. Fewer primary care doctors also mean fewer who will accept the insurance you happen to have—which, of course, limits your access to care.

More and more patients are forced to spend more and more time looking for a doctor who will accept their insurance card. Adrianne, a Peace Corps volunteer who recently returned from Guatemala, posted on the California Nurses Association’s Web site about her troubles finding a doctor who would accept the Peace Corps transitional health plan. For a week she called twenty doctors in upstate New York, before finding two who would take her as an in-network patient. “My question is,” she asked,” why was I able to get the health care I needed while living in Guatemala but now that I’m home, I’m having so much difficulty in getting my basic needs met?” Heavens! Better care in Guatemala?

It’s no wonder, then, that the Washington research shop Center for Studying Health System Change (HSC) just reported that more than 20 percent of the American population in 2007—fifty-nine million people—said they either completely avoided or delayed getting essential medical care in the previous year, a number up significantly from 2003, when 14 percent of the people reported the same problems. What gives here? Most of the people who had trouble getting care said cost was the main impediment. Many were uninsured. But even those with coverage had trouble getting their health plans to pay for treatment, and many reported that their doctor or hospital would not accept their insurance. Combine this with the looming shortage of primary care doctors, and disaster awaits.

On June 15th of this year, the Colorado SpringsGazette explored the coming medical calamity, noting that the area is short about 100 primary care doctors. The piece also offered an unconventional take on emergency room use. Conventional wisdom says that poor people freeload in the ER because they can’t pay their bills. But The Gazette’s piece notes that patients, especially those on Medicare, come to the ER for primary care because they can’t find a doctor. “You can’t fault the patient,” said Dr. Jeff Oram-Smith, chief medical officer for Penrose-St. Francis Health Services. “If they try to get a doctor’s appointment and can’t get it, there’s not a whole lot of alternatives for them.”

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.