Pop quiz. How many doctors are at the top of Mt. Everest? None, actually. Yet, think about how many people get sick up there. Think about how many die? Do you think extra bonus payments could coax a few doctors to relocate up there? What if we waived their student loan debt? If you find these questions interesting, there’s clearly something wrong with you. But cheer up. As the map below shows, there is a lot of variation in the number of people per doctors across Texas counties. [Thanks to Jason Roberson and his colleagues at The Dallas Morning News for making the data available.] At one extreme, Bandera County in the Texas Hill Country has 21,266 people and only one doctor. At the other extreme, Baylor County, near the Oklahoma border, has 666 patients per doctor.
Should we care about any of this? If so, why?
Before getting into specifics, let me address a cultural issue that I believe greatly prejudices all discussions of doctor location.
Bandera County bills itself as “The Cowboy Capital of the World.” It clearly promotes tourism. But the online reviews of its eight area restaurants don’t make me want to visit any time soon. Ditto for the online reviews of its 10 hotels, motels and dude ranches. Still, a lot of people visit there and it has a growing population.
Now (here’s the glitch) if you’re a health policy wonk living, say, in Princeton or New Haven you cannot in your wildest dreams imagine why anyone would ever voluntarily choose to live in Bandera County. Think how far away it is from the Met, from Broadway, from Avery Fisher Hall. Think how far away it is from decent Chinese or Italian cuisine. Think how far away it is from… from… well, from civilization.
So to a great many of my colleagues, underdoctored areas are natural and inevitable. What graduate of Harvard Medical School is going to want to move to Bandera? It’s hard to even imagine being able to bribe them enough with hard currency. It may require handcuffs and cattle prods, whips and chains — or whatever our 21st century courts rule is constitutionally permissible.
The problem with this kind of thinking is that it should apply to the other professions as well, if it were correct. After all, there’s nothing particularly special about medical students. So I did a quick check and found seven area listings under “lawyer,” seven under “accountant,” and seven under “engineer.” If Bandera attracted doctors at the same rate that it attracted other professionals, it would have a respectable 3,000 patient/doctor ratio!
So what makes health care different? To begin with, one-third of the U.S. population is in Medicare or Medicaid — government health insurance programs that impose price controls at a much different level than would occur in a free marketplace. A private health insurance system dominated by only a few large sellers, such as we have, then piggybacks on top of the reimbursement formulas used by those programs. Bottom line: in health care, when government dictates prices, the supply of health care cannot be properly allocated.
Another problem is that these discussions almost always ignore transportation. Surely the access issue is: how long does it take a patient to get to a doctor; not how many patients or doctors reside in any geographical area. Although this may come as a surprise to some, in most rural areas people no longer rely on horse and buggy. They almost all have… you guessed it… fossil fuel-burning vehicles. [I know. They pollute and cause global warming. A rational society would have rural free light rail. But what can you do?]
The Bandera County Chamber of Commerce, for example, lists seven Hill Country hospitals nearby, not counting San Antonio (about 70 miles from Bandera) and Austin (about 115 miles). There are a dozen or so clinics as well.
Nationwide, most people in most “underdoctored” areas are not really that far from a doctor. A somewhat dated study in The New England Journal of Medicine found that 80 percent of rural residents lived within 10 miles’ driving distance of some physician and 98 per cent lived within 25 miles.
Then, of course, there is the whole issue of medical practice laws that keep Physicians Assistants who treated our soldiers in the field in Iraq and Afghanistan from performing the same services for people who live stateside.
I’ll sign off with a possibility not considered. Instead of patients traveling to see the doctor, why not reverse the travel pattern and let the doctor to come to you. Consider this:
Family practitioner Ken Jackson is known around Kingman, Ariz., as the “Cowboy Baby Doctor,” though he says the nickname is a bit misleading — he doesn’t always ride a horse or wear his cowboy hat, and he prefers alternative rock to country music.
But for the past three years, Jackson has traveled by horseback once a month deep into the Grand Canyon to provide prenatal care for Supai, a remote Native American village of about 400 that is inaccessible by automobile. It is the last place in the USA to which the U.S. Postal Service makes deliveries by mule.
John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.