The market has not worked to attract people to rural America to care for our rural citizens (a topic for another day). After doing some research for a talk, it turns out that health care professionals are actually responding appropriately to the market:
Rural residents seeking health care are (as a rule)
- older than urban residents
- in poorer health than urban residents
- more likely to be disabled
- more likely to be uninsured
- more likely to face financial barriers in obtaining healthcare
- more likely to incur travel burdens while seeking care
- much less likely to receive services than are their urban counterparts if they suffer from serious mental illness. There are specific barriers to mental health access. These include
- Service fragmentation
- Lack of transportation
- Lack of cultural and linguistic competency
- Poor rates of Medicaid enrollment among people with mental illness
- Stigma associated with mental illness
- More poor immigrants
The south offers more complex set of problems that make the market even less likely to be effective
- Population is in decline and poverty is increasing in rural areas
- Rural poverty tends to be persistent, historically complex, self-perpetuating, and psychologically and culturally oppressive
- One third of the poor in the United States live in rural areas, and the rate of poverty in rural counties is increasing at a faster rate than it is in urban areas
- Residents of rural counties in the south are more likely to be unemployed, less likely to be Medicaid eligible
All in all, President Obama’s vision, as articulated in his speech on Wednesday, said very well why we need to work to care for our fellow citizens despite there being no profit:
But there’s always been another thread running through our history – a belief that we’re all connected, and that there are some things we can only do together, as a nation. We believe, in the words of our first Republican President, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves.
And specifically about healthcare:
We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. “There but for the grace of God go I,” we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.
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April 14, 2011 at 6:58 pm
Robert C. Bowman, M.D.
Spending Design
The policy design sends only 5% of annual health spending to primary care, a different 5% to rural locations, and a different but overlapping 5% to the most underserved areas. The three are overlapping as primary care workforce is dominant in rural and in underserved areas and nearly half of underserved populations are in rural areas.
Family Practice Multiplies
Also associated most with primary care, rural, and underserved is family practice MD, DO, NP, and PA (but only the smaller fraction of NP and PA that choose and remain in family practice). Each family practice commitment results in multiple times more distribution where needed whereas non-family practice career choice results in average (IM, PD) to less than half of average (subspecialty) distribution. Family physicians are multiple times more likely to serve the elderly, poor, near poor, rural, CHC, most underserved, and disadvantaged (Ferrer, Rosenblatt, Bowman).
Family practice stays in locations even when concentrations of patient income, health care coverage, employment, and education decline and these are more likely to be rural or underserved or both – by design.
The lower level of health spending also results in the least support personnel, facilities, and resources and often the least experienced personnel as those more experienced transition to higher paid and better supported hospital, subspecialty, or academic careers.
This is why design changes are needed to move from 5% to 8% for each of primary care and for rural and for underserved spending. This is why the nation must have permanent primary care family practice by expectation before entry, by admission, by entire training focus, and by entire careers. Also the same is required for RN, NP, and PA that hope to contribute to primary care. Non-family practice continues to concentrate in top concentrations.
Redesign is also a vehicle for recovery of lower and middle income and rural America as this sends health services, jobs, and economics where all are most needed. This is a different design than spending ever more dollars in locations with populations with higher concentrations (education spending, health care spending).
The situation has developed over the past 100 years is not a design shaped by government. The design has been shaped by those who benefit the most. The designers have consistently missed the point that what they have designed is not sustainable for best health for most people in the United States and is certainly a bad design for a sustainable economy and future for the United States.
April 20, 2011 at 9:51 pm
Improving rural health care…market or no « Training Family Doctors
[…] posted a week ago on health care and the market for rural America (and by extension, Alabama). I wanted to share with […]