Presidential Elections and Pieces of the Primary Care Puzzle

James E. Rohrer, Ph.D., Professor and Chair, Department of Health Services, Research and Management, Texas Tech University Health Sciences Center, Lubbock, Texas

As I begin to write this editorial, the presidential election is in its final 48-hour period. To some, the future is held hostage to the outcome, with one choice leading to shining opportunities and another choice leading to a new dark age. Pardon my cynicism, but I suspect that the perennial problems of rural America will persist, regardless of who next occupies the oval office. Federal health policy reflects an equilibrium of power; competing interests both within and outside of the national government have arrived at a balance that gives priority to concerns other than rural health. This reality may change a little at the margins, but no revolution in rural health policy is waiting to unfold. Instead, rural communities will be left to handle most of their problems with minimal assistance, just as they always have.

Let's consider just one of those issues: access to primary care. The problem of access to primary care places us on the horns of a dilemma: any effort to increase the supply of primary care providers in rural areas could jeapordize the livelihood of those already in practice. Just as there is only so much grass on the range, there is a limited amount of medical income that can be derived from serving a given population. The question, How many do we need? is always balanced against, How many can the community support? The second figure often is smaller than the first. Neither party has a platform plank that will solve this problem.

Fortunately, some strategies have not been given a fair test, thus, leaving us room to experiment. In many rural communities, a public health agency, rural health clinic, and physician's office can be found within a few blocks of each other while a satellite clinic affiliated with a community health center is in the next city. The public health agency clinic may lack physician input, the rural health clinic may be staffed on a part-time basis, the physician's office cannot afford to pay nurse practitioners or physicians assistants because of a shortage of patients with good insurance, and the community health center is swamped with low-income patients. Putting the pieces of this puzzle together could make a single picture that amounts to a well-managed and adequately resourced (no frills, of course) local medical care system with the potential to produce services far more effectively and efficiently than the fragmented system we now have. Yet, different funding streams, ridiculous eligibility restrictions, and turf battles prevent the puzzle pieces from becoming a pretty picture.

The federal government could reduce the level of fragmentation, of course. However, we should at least consider the possibility that the diverse funding streams could be blended informally by well-meaning, sensible, cooperative people who also are friends and neighbors. Maybe we should put all the pieces together locally and tell the federal government about it later, or not at all.