Today, President Obama told the American Medical Association that the health care system costs too much, includes too few people and is unsustainable without major changes.

“But what I refuse to do is simply create a system where insurance companies have more customers on Uncle Sam’s dime, but still fail to meet their responsibilities,” Obama says.

Many doctors agree that lack of health insurance is a big problem. But their day-to-day concerns also include a lack of time with patients and a system that has evolved into a confusing web of paperwork.

Dr. Nancy Nielsen, president of the American Medical Association, says the biggest problem is when patients don’t have health insurance.

“Every study that’s been done has shown that people who lack health insurance don’t go to the doctor for preventive care, they delay care,” she says.

Nielsen says doctors face other challenges as well, such as coordinating care when patients’ insurance plans limit the choice of doctors and hospitals. Doctors often have to pick drugs off a list of covered pharmaceuticals. And they are trying to incorporate health information technology systems into their practice, without assurances that the systems they are buying will be able to exchange information with other systems.

Family physician Richard Roberts has been practicing in tiny Belleville, Wis., for 23 years. He says the health care system’s biggest problems are that not everyone is covered, and it is very complex. He describes a mother who brought in her young son for an ear exam. He noticed she didn’t look happy, so he asked her what was wrong. Further questioning revealed that she had depression, and that her husband had started drinking. Roberts spent some time counseling her, but in the end could only bill for the 15 minute ear exam.

Roberts is most troubled by what has happened to the doctor-patient relationship.

“We don’t structure our health system to support that,” he says. Patients jump from health plan to health plan, and have to switch doctors. Physicians are paid to do procedures, not to talk to people.

But talking with patients is a vital part of being a doctor, says Roberts. “That’s the real joy of what we do, that’s the insight that allows us to do our work,” he says. “If we can redesign the system to support that, not only will people be happier but the costs also go down, because more appropriate things get done.”

Time Spent On Paperwork, Not Patients

Roberts is also disturbed by what he calls “administrivia.” He estimates he spends 15 to 20 hours a week filling out forms – Family and Medical Leave Act forms, disability forms, and insurance forms, though he says in Wisconsin the insurance forms aren’t too bad.

Oncologist Robert Fein in Somerset, N.J., says things for him are getting worse week by week. “I think the health care system is ready to implode.”

Oncologists used to be paid significantly more than it cost them to buy chemotherapy. In effort to reduce costs, both the government and insurers have substantially cut back on what they pay for chemotherapy. Fein says he sometimes gets paid less than it costs him to buy chemotherapy, and in addition, more and more patients aren’t able to pay the copayments, leaving him stuck with the balance.

He tries to help his patients by assisting them apply to drug companies for free or discounted chemotherapy drugs. But that puts him in an awkward position with his patients.

“I am now having to ask many of these patients for their tax returns so I can fill out paperwork so they can get alternative coverage for their drugs. I’m a physician, I’m not an accountant,” he says. And this isn’t what he studied in medical school.

Many Delay Care, Escalating Illness

For emergency department doctors, one of the big problems with the current health care system is the recession.

“We’re seeing newly uninsured patients, we’re seeing patients who as they get into greater financial distress are cutting corners, and delaying the care that they need,” says Arthur Kellerman, professor of medicine at Emory University. He works in the emergency department at Grady Hospital in Atlanta and sees patients who have delayed getting treatment for too long.

“By the time they come to us, they are in legitimate emergency condition with problems that are far more costly, and sometimes impossible to treat. And that’s heartbreaking,” he says.

Kellerman has seen patients with advance cancer, with heart attacks, with strokes that could have been avoided with earlier care.

In Wisconsin, family medicine doctor Richard Roberts says the health care system has to change – soon. “It’s beginning to collapse of its own stupidity,” he says.

But how should it change? He won’t say.

“The debates about whether it needs to be single payer or multipayer, I’m going to leave that to the politicians … I just want to get it done and have everybody covered.”

And, Roberts wants to go back to being a doctor full time.