And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.

The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. When you compare the percentage of physicians who are generalists with those who are specialists, the United States beats only Greece among developed economies.

Here, financial drivers play a role. Doctors who choose to specialize can make much more money, millions more dollars over a career, than primary care physicians.

Money isn’t the only reason that medical graduates choose to specialize. But it’s certainly a factor. The average student debt for someone finishing medical school in 2015 was more than $180,000. Twelve percent of graduates had debt totaling more than $300,000. The median starting salary for a resident physician (and some residencies go for seven years or more) was just over $52,000. So by the time you’re in your 30s, you are hundreds of thousands of dollars in the hole, and you’ve just spent years making too little to pay it back while interest accrued. A specialty that might offer you a lot more money is enticing.

None of this should be taken as a cry for sympathy for the financial plight of doctors in general. They are more likely to be in the top 1 percent of earners than any other profession. Still, it’s important to recognize that financial drivers are at play, and that they do matter.

What no one seems to be debating is that we have a shortage of services. We could fix that by increasing the number of physicians, either by training more or allowing more to immigrate into the country. We could fix that by improving the ratios at which physicians enter specialties or primary care, through changes in training slots or in how we pay physicians. We could fix that by making the health care system more efficient, by distributing the resources we have more effectively, or by increasing our willingness to use midlevel practitioners through changes in regulations or licensing.

None of these approaches are easy, and all would most likely require governments to act. As the next administration takes power, choosing at least one of these paths seems necessary to improve access in the health care system.