A common mistake is believing that you can impact the end points (college tracks, medical school influences, loan repayments). When you are talking about national outcomes and improvements, the end points are far too late as they are dependent upon "the matrix of relationships" as Deming often noted. Previous life experiences shape subsequent encounters and situations. Health care is one of the ultimate examples of complexity - and even the best research fails to consider the numerous pre-existing influences that shape health outcomes.
Prevention of higher education and medical school from the start.
- The United States is dead last in child well being. This acts to prevent most American children from higher education and a path to medicine (Unicef Report Card 11)
- The United States invests little in age 0 – 6 compared to nations doing well in child well being and in subsequent education and other outcomes (Unicef).
- The United States fails in education finance. School districts must depend upon a local tax base and property values – a design for less for most American children.
- States behind the most often thrust even more responsibility on school districts with lesser property value (Strange School Funding Formulas, Baker and Corcoran in Education Trust Funding Inequities, others). Is School Funding Fair?
- Children from higher, middle, and lower property value school districts layer out such that even the lowest performing in the higher property value districts can outperform the best of the lower value districts.
- The United States fails in higher education as few children other than those from highest income families can access the colleges that lead to medical education and other advanced degrees.
Each of these results in disadvantage for most children as measured by lower probability of higher education and medical school admission as well as higher probability for children of advantage.
Dividing the Nation By Income in Medical School Admission
- Over 60% of Medical Students arise from the top 20% in Parent Income (AAMC data)
- 20% arise from the second 20% - equity
- Less than 20% arise from the bottom 60% of American children (AAMC data)
- Lower income rural county origins and Mexican American populations have 5 times lower probability of admission
- 74% of the College Students for the top 146 colleges arise from the top 25% of the Nation’s Children as rated by socioeconomics (Carnevale and Rose, New Century Foundation, Left Behind for a 3 to 1 Ratio Favoring Those Are Most Advantaged
- Race and ethnicity are often cited as representing major differences. One problem with race/ethnicity is that ethnicity involves differences in income, education level, geographic location, and other dimensions.
- Asian origins are higher income and most urban and are associated with a 3 times greater probability of medical school admission with over 20% of medical students despite less than 6% of the population. The highest income most urban Asian Indian component is an 8 times greater probability or 7% of medical students with less than 1% of age 18 - 24 in the US population. The same highest ratios apply for highest income, most urban, children of professionals/highest educated parents.
- Rural origin physicians have declined from over 25% of physicians entering the workforce to less than 7% in the past 50 years with white rural US born males down to 2%. Increases in non-white, foreign born, urban, higher income origin, and female physicians are a poor fit for rural areas as each dimension more likely to distribute is in decline - steadily replaced by those less or least likely to distribute.
Even when not gaining admission to a US MD school, the expanding osteopathic and Caribbean opportunities and other international schools (US born Asians going to Asian nations for medical school) offer more routes to becoming a physician.
Normal children in America have little chance with lesser opportunity shaped by design. Those most different and unlike most Americans in a number of dimensions are more likely to become US physicians.
- Are least likely to choose primary care
- Are least likely to remain in primary care when training in primary care
- Are least likely to choose family medicine
- Are least likely to remain in core specialties
- Are least likely to distribute where needed
- Often move state to state, failing to remain in states in need of workforce - reinforced by more specialized careers that dictate states, counties, zip codes, and practices
- Represent 33 - 40% of physician workforce where workforce is needed
- Are the most important sources of health care for the elderly populations that are doubling from 2010 to 2040
- Are the most important sources where counties are growing the fastest in population growth and in primary care demand.
- Since internal medicine primary care is steadily declining, the family practice sources are even more important.
The United States will continue to produce Too Many and Still the Wrong Physicians
- Instate location for 30 states behind, not 6 - 10 states with top concentrations of physicians and graduate medical education
- Primary care - permanent over a career, not just during training
- Workforce in counties and zip codes in need of workforce such as 2600 counties with lowest concentrations of clinicians and 40% of the United States population
- In graduate medical education, our teaching institutions cling to their funds and produce ever higher specialized workforce - preventing workforce needed for most Americans.
- Highly specialized physicians, the institutions, and their associations cling to higher payment for their services defeating primary care payment (half of the services) and the primary care workforce that is half of the physician workforce where care is needed.
- Urban power overcomes rural need as the formulas that determine federal spending can send funds to school districts with higher concentrations of kids in poverty but lower percentages (7 - 10%) while the spending fails for rural school districts with higher poverty but lower concentrations of impoverished kids.
- Lower and middle income children have received little help with higher education funding support as the colleges dangle scholarships in front of higher income parents - parents who can afford to pay higher tuition and may also support the colleges in other ways.
- Stalled progress in higher education opportunity has reached the attention of the nation's top experts, but little has been done.
Parents need to understand what happens in education. In the classroom, in the school, in the district, and in the state, the key measures are about the 50% left behind, not the few doing well. Those doing well have numerous advantages and will likely do well without investments in child development, early education, or catch up programming. For most American children, these recovery investments are essential. When the designers decide that cuts on costs are the only dictate, the powerful parents will direct the remaining funds to their children.
Most Americans will lose in this process of squeezes within squeezes, leaving an entire nation further behind.
Worsening disparities will continue to make matters worse
What we understand about social determinants indicates that declines in income, education, and other determinants will shape worsening health outcomes. Cash flow into an area can aid in development and recovery. Cash flow restrictions or requirements to send cash outside of an area can result in social determinant changes such as declines in jobs, income, and other areas. Rural and single county hospital closures are an example of such declines. An acceleration of closures of practices and hospitals where needed is the small scale example. State and national changes indicate massive changes in cash flow.
- Federal and state funding cuts in child development, education, nutrition, Social Security, and health care where needed will worsen cash flow, jobs, economic impact, and situations where disparities exist as these are areas even more dependent upon these investments.
- Downsizing business changes, centralization of government positions (social services, extension), mergers of businesses and health care, and consolidations of schools all represent compromises of cash flow, jobs, income,
- Largest urban and rural systems take over those smaller. Some even proceed despite violations of the law. Local health care needs and local cash flow are compromised while centralized location benefit.
- Mail order prescriptions took billions away from local pharmacies and economics while centralizing spending in just a few US locations.
- Requirements for health care providers to spend more for consultants, software, and other "advances" will send more dollars out of counties in need of spending. Practices will not be able to support local workforce as delivery personnel must decline to pay more for non-delivery budget items.
Unicef Report Card 11
NYTimes Update of Higher Education Access Deficits
Admission Ratios - Highest income, most urban, children of professionals/highest educated parents
Houston Chronicle Article Regarding Discrimination in State Education Funding