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Source: Pirani and Hart, in-press.
FINDING 1: Although geographic maldistribution of physicians persists in both rural and urban areas despite rapid increases in the physician-to-population ratio, the lack of health insurance presents the greatest barrier to medical care. It is impossible to disentangle the issue of geographic maldistribution from that of health insurance. The most direct and efficient way to ensure health care access to underserved populations is to provide them with health insurance coverage and then address the residual problem of maldistribution with focused programs that deploy health professionals to places with insufficient providers. Even though progress in this area has been erratic, incremental improvements continue to be made. Recommendation 1: Continue to develop policies that increase the proportion of the population with health insurance coverage. FINDING 2: In the absence of universal health insurance, safety net programs such as the CHCs and the NHSC are essential mechanisms for insuring access to health care for underserved populations. Because the process of expanding health insurance is likely to be incremental, large segments of the population will continue to be underserved for the foreseeable future. The nation will continue to need a flexible set of programs that allow the establishment of federal, state, and local partnerships that sponsor health clinics that provide medical care at reduced cost to needy populations. The community and migrant health centers and the NHSC afford such vehicles, allowing local communities to recruit clinicians and establish delivery systems that at least partially address the problems of geographic maldistribution, poverty, cultural isolation, and lack of health insurance. Neither program is perfect. Physicians who accept federal scholarships and loan forgiveness in return for future service in the NHSC are not always happy with the locations where they are subsequently expected to serve, and long-term retention in underserved areas is a desirable but often unattainable goal. Yet despite these problems, there are few viable alternatives that could be implemented on a national basis. As the safety net frays under the weight of increasing numbers of uninsured, these vital delivery systems should be preserved and strengthened. Marginal increases or approaches are unlikely to be adequate to address the enormous need. Recommendation 2: Significantly increase the NHSC to enable it to serve the growing number of underserved people in rural and urban areas. Recommendation 3: Significantly increase funding for CHCs and other safety-net programs to enable them to serve the growing number of underserved people in rural and urban areas. Recommendation 4: Create a joint federal-state- local strategy for expanding the spectrum of safety net activities to ensure that underserved populations receive adequate access to the full range of appropriate health services.
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