Next week, Alabama voters will have an opportunity to do direct democracy. We, the voters, not our elected representatives, will make the call. Will we continue to operate essential state functions by using our state savings account, the Alabama Trust Fund? Or will we fold and hand the decision back to folks who have already shown they can’t do it right?
I’m voting Yes. It was not an easy decision. Like many of you, I am frustrated that our elected representatives could not do an effective job and that this has been thrown in our laps for political convenience, not because they really care what we think. There are more responsible ways to manage our state budget, and it is tempting to think we could force a better choice by voting no. I’ll get to my thoughts on why that isn’t likely in my last piece this week.
There’s another reason progressives give for their No, and this one chills me to the bone. Some people think that if we vote no and Montgomery fails to fix it, enough suffering will happen that voters will cry foul and either immediately force a funding change or vote this crowd out of office in 2014. I can’t go there, for both political and ethical reasons, because the suffering will fall too heavily on the voiceless, the children, who shouldn’t be held to account for the votes of their parents. I know there are other groups served by Medicaid, including persons who are disabled or elderly, and that there are other functions of the state affected by the vote next week. Right now, though, it’s hard for me to think about anything but the children.
For those who can grit their teeth and consider the nuclear No option, I’m wondering if this rests on the expectation that once funding is fully restored, whether after a few months in 2013 or later in 2014, we can quickly revive services we lost. For medical care, that simply isn’t true. A short lapse in adequate funding, including payment delays from “temporary cash flow” problems, could create a disaster that will take years if not decades to overcome. If you think Obama got a raw deal inheriting the Bush economy, you need to think twice about your No. A new group in 2014, no matter how good they are, could not possibly repair the damage in time to let voters notice a difference. Don’t set your candidates up to fail.
Today, I’ll focus on rural medicine, and later this week I’ll address the somewhat different situation in semi-urban and urban areas.
The life of a rural physician is hard, not only for financial reasons. In fact, rural life can just be hard, period, for people who are not accustomed to it. I come from Tuscaloosa, and I did practice for about 1.5 years in rural North Carolina before my family returned to our home state. It was lovely, and the people were marvelous, but Lord, have mercy. There was no pediatric emergency room, no neonatologist, no pediatric specialist—we were it, at all hours.
In small places, a doctor is really never off call. My residency program had an arrangement with the only pediatrician in a small town nearby. Once a month, a senior resident would drive down and stay in a hotel to cover the practice for the weekend. The pediatrician had learned the only way he could use this time off to be with his family was to leave town completely and tell no one where he was going. Otherwise, the patients would find him. For parents with young children, this is wearing. I left my daughter’s 5year old birthday party to help one unexpectedly busy Saturday when I was supposed to be off. It might sound trivial, but she can’t get that day back, and as you can see I still feel bad about it. I have tremendous admiration for doctors with enough commitment and character who stay and serve their patients. They are truly heroes in my book.
That’s why the retention rate for doctors is far higher for those who grew up there and appreciate the wonderful parts so much they return after training. It is higher when they have mentoring contact during training with established rural doctors. And it is higher when there are other doctors already in the community, so that they can share call responsibilities and have a network of support.
We have in our state two initiatives that take these factors into account, the Rural Medical Scholars Program and the Rural Medical Program. Simple loan repayment plans that help doctors afford training in exchange for a term of work in an underserved community have a degree of success, but far too many graduates leave the area when they’ve finished their obligation. Alabama’s programs have a different approach—they identify potential doctors in rural areas years in advance and begin prepping them for long-term practice. The results have been phenomenal. I help teach many of the students and Family Practice residents who participate—it is an honor to contribute to the health of rural communities in my state.
These rural doctors are the first who will feel the effects of Medicaid payment cuts or delays, even if short term. Sure, some will take out loans as they had to last spring during the payment delays, but if this is the second time in a year, maybe not. They may just have to make the painful decision to relocate, perhaps even out of state. They are talking about it already, because of the constant uncertainty. Others close to retirement may decide the time to end their careers is at hand. When these doctors leave—uproot their families, sell their homes, and get established in new locations (hard and stressful to do for doctors in primary care, where we are used to building long-term relationships with patients)—they will not turn around and come back upon the restoration of funding.
How long would it take us to get other doctors into those places? The work of recruiting through the Rural Medical Program begins at least 7 to 8 years in advance- at the end of college, followed by 4 years of medical school and 3 years of residency. There is even some contact with interested high school seniors. Those close to finishing residency next summer will hesitate to go into practice in communities where the established doctors have just left the state, and they are making these decisions and interviewing for jobs right now. The others, if they lose access to rural mentors during earlier parts of their training, are less likely to choose rural practice at all. I’ve told you about the domino effect before—the doctors leave, the nurses and other medical employees have nowhere to work, and the hospitals without staff can’t help you.
I talked to Dr. Bill Coleman, director of Huntsville’s Rural Medicine Program, a few days ago. He told me that interest in rural practice, partly because of all these years of effort, has been increasing—he said we were “on the cusp” of significantly expanding our rural physician infrastructure. He is dismayed at the possibility we could lose the doctors serving as mentors, already at maximum capacity and serving at financial cost to themselves. He has put his heart and soul into this work, now coming to fruition. What a useless waste, for all that time and sweat to be undone in a fit of political posturing.
I’m voting Yes next Tuesday. My Yes is not to the politicians who have failed us or to the irresponsible misuse of funds. My Yes is to these honorable men and women who have put their lives into serving the rural poor and to the children in their care. Will you join me?