Monday, January 11, 2010

No country for health care: rural medicine in America

Thanks to Dr. Fitzhugh Mullan and colleagues at the Medical Education Futures Study for letting me know about a terrific 4-part series of articles by Emily Ramshaw of the Texas Tribune. In "No Country for Health Care," Ramshaw documents the severe difficulties that residents of rural Texas have in accessing primary and specialty care services. While most of the national health reform debate has revolved around providing insurance coverage to more people, this series illustrates the profound challenges of obtaining medical care in these and other similar regions of the U.S., insured or not:

Many Texans live more than an hour from basic medical care. Some border communities have so little health care that U.S. citizens cross over into Mexico to get it. ... 63 Texas counties have no hospital. 27 counties have no primary care physicians, and 16 have only one.

Conventional solutions to this shortage of rural health providers - offering scholarships and loan repayment incentives to doctors who choose to practice in underserved areas and changing medical school curricula to increase exposure to rural medicine - have proved woefully inadequate to the task. As the urban population has increased relative to that in rural counties, fewer legislators are able to advocate for rural health needs, and recruitment of new doctors has become nearly impossible. (Cities, in contrast, usually have a glut of doctors - the District of Columbia, for example, has more nonfederal physicians per capita than any state in the U.S.)

Despite a recent infusion of federal stimulus funds, the National Health Service Corps is not, and probably never will, be enough to compensate for the tendency for physicians (and other types of clinicians) to gravitate toward urban and suburban lifestyles. Health care reformers need to come up with more creative solutions. Telemedicine may be part of the answer; old-fashioned house call practices might be another. No strategy can possibly succeed, however, in the absence of a coordinated and determined effort to train more family physicians.

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