I’ve just returned from a hospital meeting at which some take-all-comers, mission-driven hospitals are seeing bad debt ratios of up to 12% of patients, and at the same time the National Association of Community Health Centers reports that 36 million Americans lack access to basic care. These are not just the uninsured, some of whom do get access to care–hence the 12% bad debt ratio at that hospital. And don’t forget that at any one time 1 in 7 Americans is uninsured.

But roughly half the 36 million do have some level of insurance, even if it’s Medicaid (which in a state like Texas is barely what most of us would recognize as health insurance). The problem is not so much insurance as it is access to providers. As Dan Hawkins, Vice President For Policy at NACHC said:

"They live in inner-cities and in isolated rural communities. But no matter where they live, the story is the same: they can’t get health care because there aren’t enough doctors in their communities who are willing or able to care for them."

The dirty little secret of American health care is that although we have an over abundant supply of facilities and doctors on a national level, at a micro-regional level there are areas that are severely under-served. Many rural regions have less than one-third the number of doctors per head that are seen in affluent suburbs, and if you are living in an inner city area, the experience is similar. The dedicated folks doing the worthy work at community health centers and in county hospitals are desperate to get this message across. Dr. Gary Wiltz, MD, Executive and Medical Director of Teche Action Board in Franklin, Louisiana said:

"Where the unserved live, there are higher rates of infant and childhood illnesses, and higher mortality rates. In my state, which is the most medically unserved state in the union, we have a diabetes rate that is out of control–and that is because the diabetics who need help don’t have a doctor, or can’t go to a doctor because they don’t have transportation; or can’t afford a doctor, or even the medicines they prescribe."

This doesn’t stop when patients become eligible for Medicare, even though it’s not supposed to be a "separate but equal" system as Medicaid tends to be. Several reports including this one about knee surgery rates published in the New England Journal of Medicine last year, or this one in JAMA about access rates for Medicare HMO enrollees show that minority populations are less likely to get care than whites. And it’s not racism on the part of plans or providers that’s the cause. The problem is that there are fewer providers where minorities tend to live.

Of course the health service researcher cynics amongst us might think that minorities are doing better because they get less care, but a Kaiser Family Foundation report shows that being poor, non-white, un or underinsured and having problems with language severely restricts access to care, and results in much poorer health outcomes for those groups. For instance:

One result of limited access to primary and preventive health care is an increase in the extent to which patients are hospitalized for conditions, like asthma, that could be avoided with appropriate primary care. Gaskin and Hoffman found that Latino children and African American adults were more likely to be hospitalized for such preventable disorders than similar white patients. Disparities in access to care are not a new or recently discovered phenomenon; studies done in the mid-1980s found that Latino adults and children had substantially less access to a variety of health care services than their white peers.

Sadly the political impact of this report will barely make a ripple in the sea of the healthcare system it’s dropped into.