Bipartisan Senators Raise Rural Health Concerns

This headline is amazing in numerous dimensions - Bipartisan, 33 Senators together, showing concern for rural health!

But why have these 33 Senators not done more. More importantly, why have 70 Senators from 35 states not stood up for health care in their states - states left behind by the US health care design.

The health care design developed over recent decades clearly favors 6 states. 
What have Senators in 30 - 35 states been doing all of this time?


The Senate may well hold the key to addressing needed health care reform. The reform that is needed is not about insurance reform or penalizing more providers for meaningless reasons. The reform that is needed is to redirect spending from few states, providers, and locations to many states, providers, and locations - all who are in greater need of care. 

Like it or not, the design of the Senate favors numbers of states, even when the states have low levels of population. Senators could do more for their states.

Health care and training design works great for 250 counties, 3400 zip codes, and about 6 states using geographic coding. These are the states, counties, and zip codes with higher to highest concentrations of physicians and health care services (and health spending and jobs and economics). 

Half of the economic impact of medical education or 250 billion goes to a few dozen counties in 6 states, according to the AAMC. Because training is concentrated in these few counties and states, physicians tend to concentrate in the same locations. Health spending follows workforce and workforce shapes health spending. Both are impacted by the design of health care. 

So much for so few leaves much less for so many. The health care designs for payment and for training fail for 30 – 35 states. This still translates to 60 – 70 votes in the Senate. Senators representing these states need to work to gain more health spending for their states. The decades of toleration of lower health spending should be coming to an end. Redistribution of spending and redistribution of workforce and redistribution of training is required for numerous reasons - especially Americans in states, counties, and zip codes left far behind. 

The current health care designs result in the least training in these states and the fewest physicians and other clinicians in these states. These are states more dependent upon primary care and basic services – services marginalized in payment by decades of designs. 

Why would the great majority of Senators allow their states to fall further behind 
in jobs, economic impact, and health care?

If 60 – 70 Senators stood up for their states, the design could be changed - or perhaps not. Congress already acted over a decade ago to shift graduate medical education positions. The intention was to redistribute GME positions to states in need, to primary care positions, and to rural training locations. Unfortunately the training institutions managed to thwart the will of Congress with failures on all three counts (Chen et al).  Medical education institutions demonstrated that they were more powerful Congress in this matter. The also have managed to self fund thousands of fellowship positions. They have increased subsubspecialty fellowship positions by 11% a year for the past 10 years and subspecialty fellowship positions by 4% (Jolly, Academic Medicine). This is clearly winner take all by designs of training, revenue, workforce, etc. And in addition the institutions have been lobbying for over a decade to increase the billions given to them via Medicare.

Senators need to be able to say that workforce is growing in their states - all kinds of workforce, all kinds of training, all kinds of health care jobs, all kinds of economic impacts. 

Changes in Payment Design

What do 35 states, 2600 counties, and 40,000 zip codes need to improve health care, health care spending, economics from health care, and numerous other benefits?

These are locations that depend more upon basic services - basic primary care, mental health, general surgical services, services most common to small hospitals. More for more services is best for more Americans in more places in need of care. 

The 35 states need their 70 Senators to understand that our national designers have been steadily underfunding the basic services most important to their states - with devastating consequences to small practices and small hospitals. The formulas have been flawed for three decades with more to come. The squeals of the few doing well have been heard while the consequences across the land continue.

Senators Are the Key to Recovery of Small Health Care and Care Where Needed 

Why is there such poor representation for 40% of Americans that continue to have health system failure in 2600 counties. These 2600 counties have lower tolowest concentrations of clinicians and least local health spending - by national design!

Congress loves Veterans, but 50% of Veterans reside in 2600 counties behind by design. Rural health is important with 75% of rural Americans found in these 2600 counties, but this is only 45 million Americans. The 80 million urban Americans in these counties are also behind. When 120 million are left behind, it is bad enough. But these are the counties that are growing the fastest and growing fastest in demand for primary care and basic services. These are the counties losing workforce and hospitals, 

Improving care is important for those found in 2600 counties with 50% of Veterans, 70% of rural Americans, 33% of urban Americans, 45% of the elderly/Medicare, 45% of the poor/Medicaid and working poor. The designs for payment and for training leave them behind by design.

How Can Senators Jump on the Bandwagon that Matters for Their State?

Senators who care about health care can start by supporting basic services and access. Veterans clearly have had failures in access. Years of access failure have been made worse by coverups. 

Coverups remain the major problem preventing recovery of access for rural Americans, the elderly, the poor, and people in 2600 counties in need of care. Decades of designs continue to concentrate health care elsewhere, leaving them behind.

Access recovery is the first step toward health care of any kind and the most important step toward quality care. Without access, it is no care by design.


Access deaths are not easily determined – like hospital errors or other direct impacts. But tens of thousands of deaths should be considered important.


The designs continue to kill off more small practices (45% of primary care), more emergency rooms (domino effect for more), and more small hospitals.

How many revenue streams have been closing off? How many small health entities are being penalized where care is needed, let me count the ways...

Failure in General Surgical Workforce is a Case in Point

General surgical workforce (GS, Gen OBGYN, Uro, Ortho...) is declining by 2 to 3 percentage points each year - by national designs for training and poor payment for basic services. Comparisons of the AMA Masterfile active physicians 2005 to 2013 reveal this sad fact. Also the physicians in the counties in need of workforce are nearest to retirement - counties that have the most rapid increases in need for basic surgical services. Senators should be crying out for care for seniors and others rapidly increasing - if for nothing else other than their votes. Where is the primary care that Veterans, seniors, and others need? The answer is that it has been forced into stagnation by payment design and training design. 

Top Concentrations of Workforce and Health Spending Work for Few and Fail for Many

The health care designers are concentrated in a few institutions, associations, corporations, and government positions. The focus of the designers can be seen by who wins and who loses under the design. The design prospers those in 1100 zip codes in 1% of the land area with 12% of Americans and 45% of physicians and top concentrations of clinicians of all types and top health spending it will be all lines of revenue with the top reimbursement by a design that they shaped. SGR works well for physicians who are concentrated and fails for physicians who are distributed where needed – and their states, counties, zip codes, and neighbors. (Physician Distribution By Concentration)

Graduate training design is the last and most important training influence with regard to future practice location over a career. GME training is a 20 – 40 times multiplier of instate practice location using data on all active physicians in the AMA Masterfile.

GME design so concentrated in so few states and locations fails for 30 states, for 40,000 zip codes, and for most Americans. The failure involves care needs that could have been provided by residents and faculty during training. The failure continues throughout the decades of the careers of the physicians trained. The failure has continued despite the action of Congress to attempt GME reform.

Senators who truly care about having care could stand up with their 60 - 70 votes for their 30 - 35 states in need. They should stop giving way to the 6 - 10 states that get the lion's share of the benefits and still find ways to grab even more.

Senators Need More Pages of Substantive Change, Fewer Signature Pages

The document sent to CMS by the 33 Senators contains 3 pagesof signatures and part of 1 page of concerns expressed. I would have been happier with 3 pages filled with the problems with only one page for signatures...

The 30 – 35 states, 2600 counties, and 40,000 zip codes in need of better care also depend upon better distributions of other funding outside of health care. These are also places where populations benefit from the equitable distribution of Social Security spending, nutrition spending (Food Stamps), child development, unemployment, and basic education. Sequestration and other across the board cuts have been painful to locations already behind. Disproportionate share spending cuts were a direct blow. These are also counties that used to get billions for payment in lieu of taxes since they cannot tax federal lands to take care of their schools, law enforcement, and other basic needs. Critical Access Hospital spending has also been targeted. 

Over and over again the programs that are targeted for cuts are the programs most important to most Americans and Americans most in need of such funding. The cuts for many would help the few to do better at the cost of the many – in jobs, economics, health care, education, and more.

Regardless of the outcome of elections, Senators must be responsible for their state needs – and responsive to the populations that still remain behind by health and other designs.  

Improving Health Care is Not Likely for 2600 Counties

Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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