The distribution of medical care

One of the things that caught my eye when reading up on tonight’s State of the Union address is the claim that 1,500 U.S. counties lack an obstetrician because malpractice lawsuits are forcing physicians to stop practicing. There’s great debate about the relationship between lawsuits and insurance costs, though most research associates rising premiums primarily with declining investment revenues for insurers (for example, see this article from Health Affairs).

But what I really want to consider (albeit briefly) is the question of distribution. It’s likely correct that 1,500 counties lack an obstetrician, but it’s highly unlikely that this is because of high premiums. Instead, it’s about geography and the broader structuring of medical professions. More than half of the approximately 3,100 counties in the U.S. lack a pediatrician, and one county in twenty has no physician at all. Physicians, especially those in specialty fields, tend to practice in more urban areas, where facilities are newer, support is better, and salaries are higher. There are numerous incentives to bring new physicians to rural counties, such as partial forgiveness of student loans, but it’s tough to compete with the benefits that come from large hospitals and happening downtowns. Medical specialists simply aren’t distributed evenly, and it’s not a new phenomenon.

The issue of distribution further complicates the debate over the prerogative of pharmacists or physicians to refuse to provide certain services. There are plenty of places in this country where patients cannot simply go to another provider because there’s just nobody else to see. The privileges that come with being a physician (edit: or pharmacist) are not free, but come at the cost of an ethic of service that accompanies professional work.


Update: The Tucson Weekly this week has a story on rural health care, which adds a bit more data to the discussion:

Statistics from the National Rural Health Association reveal that Mariposa is hardly alone in this struggle. While a quarter of Americans live in rural areas, those areas are served by only 10 percent of the nation’s doctors. For specialized care, the gap is even greater, with only 40.1 specialists per 100,000 residents in rural areas, compared to 134.1 specialists per 100,000 in cities.

The NRHA is the same organization to which Jeff links in the comment, by the way. Double coincidence!