In the coming year, millions of currently uninsured Californians will gain coverage under the federal Affordable Care Act — but that does not necessarily mean it will be any easier for them to see a doctor.
As the state prepares for the expected onslaught of newly insured patients, health-care professionals are warning there may not be enough doctors — particularly, those practicing primary care — to meet the increased demand. Some say that the problem will be even more amplified in rural California, which already suffers a physician shortage and dwindling workforce, as the majority of rural physicians nears retirement and recruitment of new doctors lags in replacing them.
“The country family docs are getting old and retiring, and the younger folks don’t necessarily want to come out the remote areas,” said Dave Jones, board president of the California State Rural Health Association.
Jones, who is also CEO of the nonprofit Mountain Valleys Health Centers in northeastern California, said that it’s always been challenge to recruit young physicians to replace their predecessors. One factor, he said, is a difference in lifestyle choice.
“Country doctors doing family practice is kind of a 24/7 job,” Jones said. “What we find is that many of the young docs go into specialties because they do get paid more, their hours are more regular and they have a better lifestyle.”
Indeed, the trend toward doctors practicing medical specialties has been seen statewide, with only about a third of active physicians practicing primary care. As for the physician workforce as a whole, the state is also experiencing an uneven distribution, with 60 percent of doctors practicing in only five counties, as reported by Association of American Medical College
“It has been an issue for a long time; with the Affordable Care Act coming in and looking more toward wellness and primary care, it’s going to make it even harder,” Jones said.
While Jones applauds the health reform’s increased emphasis on primary and preventative care, he cautions it will be for naught if the workforce shortage is not taken into account.
“I certainly think the intent is really good — and that’s to promote wellness, keep people well and keep them out of the hospital, which is better for all of us,” Jones said. “All of that is good, it just means that we need more primary care providers to do that.”
Of course, not all doctors-in-training are shying away from the rural areas. Some, in fact, prefer it.
Alexa Calfee, a second-year medical student at UC Davis, said she finds rural medicine to be the most exciting. She is enrolled in the UC’s Rural-PRIME (Programs in Medical Education), which was established at UC Davis to help alleviate health disparities in rural California.
“Family practice, especially in a rural area, is the frontline of medicine. You see a wide variety and you need to work with people to help solve their problems [that] can range from an agricultural injury to an injury in the wilderness to chronic care conditions,” said Calfee. “The variety is huge and you could be the only doctor for hundreds of miles. I just think that’s an exciting place to be.”
Calfee, herself a native of rural Yolo County, ideally would like to be a general practitioner in a small rural clinic. She knows she probably won’t make as much money as doctors in urban areas or those who go into specialties, but hopes it ultimately won’t impact her decision or ability to pay of her student loans after medical school.
In California, patients living in rural areas are less likely to have private insurance than their urban counterparts. And while many of them are covered by Medi-Cal, the state’s insurance program has an infamously bad track record when it comes to reimbursements. But soon some of that burden may be lifted, with the federal government footing the bill for the state’s insurance program for the next three years under the Affordable Care Act. Some are hoping better reimbursements will create more incentive for doctors to work in rural areas.
“It’s not a shock that there’s a provider shortage in a place where there’s 25 percent uninsured patients,” said Anthony Wright, executive director of Health Access, a healthcare consumer advocacy group in California. “If you create a lot more paying customers by getting them insured…the hope is that the market will adjust in terms of having more [doctors] there.”
Wright also pointed out that though the newly insured patients are becoming more visible, the need for medical services has always been there.
“It’s not like the newly insured don’t exist in our health system already. It’s not like they’re suddenly entering the health-care system from nowhere,” Wright said. “[They] are getting care, but in the least efficient, most expensive way possible.”
In rural California, the expense also translates to poorer health outcomes than in urban areas, according to studies cited by the California State Rural Health Association. For instance, patients in rural areas were more likely to have suffered strokes, heart attacks, and diabetes than their urban counterparts; smoking and alcoholism are more common; and a higher portion of rural residents have self-reported suffering depression, stress, and other mental issues, as well as rating their overall health as poor.
“The more I learned about rural health, the more I saw that this is a huge problem in the state of California and it’s not being addressed,” said Gaber Saleh, who is also a second-year medical student in the UC Davis Rural PRIME program.
Saleh wants to practice in rural areas because that’s where he sees the greatest need. He said the health disparities and access issues in rural California remind him of problems he observed visiting Yemen, where his parents are from. “I can’t help the people in Yemen, but I can do something about the problems here,” said Saleh, who was born and raised in Contra Costa County.
In addition to needing to increase the primary care workforce in rural areas, Saleh says the state needs to work on diversifying its physician pool, not only in terms of ethnic, but also socio-economic backgrounds.
“It makes a big difference when the person treating you looks like you — even beyond that, it’s not just about having the same skin color as you, but at least understanding where you’re coming from,” he said.
And as far as the likelihood of earning less money than a specialist in an urban practice?
“It doesn’t bother me at all. As a physician you make a great salary” — which Saleh estimated to be $150,000 to $180,000 a year for primary care physicians — “When did that become chump change?”
Even with the cost of medical school, Saleh dismisses monetary incentives for recruiting and retaining physicians in rural areas.
“The idea now that’s being thrown around is you increase the salaries of primary care physicians,” he said. “Is that really the direction we need to go though? Aren’t we just adding to the cost of health care rather than bringing it down?”