Improving Health Care Is Not Likely for 2600 Counties

Commonwealth indicated six areas where the US is behind compared to the United Kingdom.  Actually fixing health care requires fixing far more than health care or distributions of health care. The truth is that nations have better or worse health care due to distributions of income, economics, education, and other factors that shape health, health care, and health care outcomes.

It is often not possible to fix health care woes by health care focus.

For the United States to actually improve in health, the substantial populations of Americans that are behind would have to be addressed. What happens to 40% of Americans in 2600 counties with lowest concentrations of clinicians is paramount to recovery of health care. If the US does not address situations in 2600 counties, it will not improve American health care.

United States Health Spending Excesses

Direct attempts to cut health spending have typically resulted in across the board cuts in spending with small health care and rural health care most impacted – as well as 2600 counties in need of health care that are most dependent upon small health, primary care, and basic services. Lowest payment for these areas shapes decline by design.

Redistribution of excess spending has not progressed - those who spend so much have been too powerful and there are many advocacy groups that resist spending cuts for "their kind" of patients.

Unfortunately basic services have no advocates. Further cuts are likely and are likely to damage health, economics, and more in 2600 counties behind by design.

Delays in Access

In areas with higher concentrations of clinicians, utilization is multiple times higher. Patients with higher income, better paying health plans, and numerous health concerns dominate overuse. Meanwhile locations with lower concentrations of physicians have serious problems accessing care.

While Commonwealth states that access to specialists may be better in America, this is not the case in 2600 counties where specialists are few and where even fewer are found with each passing year.

The for-profit design of US care has guided too much workforce where clinicians are concentrated and less workforce where clinicians are needed.

Delays will worsen for a number of reasons. Populations are growing fastest in 2600 counties as are numbers of elderly and highest health care demand patients. More demand plus stagnant or declining supply means delays in access.

Patients Go Without Care Due to Cost

High deductible insurance is more likely where care is needed. Populations still in need of insurance or income or both are more likely to be found where care is needed. Costs of care can be higher where care is needed – where patients must transport farther with more disruptions to lives or jobs.

Too Many Emergency Room Visits

Fewer providers, hospital and ER closures, health literacy issues, deficits of primary care, lack of convenience/urgent/retail care all lead to more ER visits. Counties in most need of workforce share all these and more.

Preventable Death Rates Too High

The 2600 Counties have higher to highest preventable death rates. Once again this is about many factors such as poor access, deficits of primary care, risky occupations, more travel, poor roads, low health literacy, higher obesity, higher diabetes, and more. Simple changes in health care are not going to change the many factors that result in this problem. The 2600 counties also have higher rates of preventable hospitalization and higher readmission levels - shaped by these same situations and determinants. Penalty formulas cannot discriminate between poor care and care of poor people - thus penalties will make matters worse where care is needed. 

Higher Infant Death Rates

Infant mortality has long been understood as a measure of success or failure as a society. Societal issues, poverty, income divisions, psychosocial situations, housing, various environments, relationships, poor support, and situations facing the children who become mothers.

None of these areas can be fixed by a direct attempt to cut costs, graduate more clinicians, reform insurance, or regulate patients or providers.

A War on Poverty is the closest approach to improving these areas. The US has been heading in the opposite direction since 1980 in a number of areas, especially in health care.

Reversing decades of payment failure and health professional training failure will take much more and in many areas that impact health directly or indirectly.


Commonwealth Comparison US to UK

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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