The U.S. health care system is poised to undergo seismic changes for the foreseeable future. More concerning are the staggering implications for our nations communities as the realities of this conflagration begin to take shape.

Today’s health care system is overburdened by crowded emergency rooms, overworked medical professionals, and dwindling resources to pay for it all a clearly unsustainable scenario. The American Hospital Association reports that more than 35 million patients are admitted to the hospital each year. More alarming is the estimated 118 million that are treated in emergency departments for ailments that could be handled easily by primary care physicians. Urban hospitals have been particularly hard hit, with more than 65% of facilities reporting at or over capacity.

Discussions of health reform are ubiquitous these days.  Our media airways are choked with sound bites of congressional proposals, harsh partisan rhetoric and “death panels pulling the plug on grandma.” Even advanced health policy thinkers are overwhelmed by the barrage of opinions and discourse on the topic.

Questions abound on how to fix such a massive, complicated issue. Much of the challenge centers on addressing the vast demographic differences that exist in the U.S. today: cultural, lifestyle, gender, socioeconomic, and myriad other factors have to be taken into consideration.

For true transformation to occur, a “New Geography of Health Care” must involve a sea-change in three fundamental areas of reform: access, quality, and cost. Let’s take an in-depth look at the challenges as well as the opportunities associated with each of these areas.


Talk of reform is wonderful fodder for the airways, but if the government successfully overhauls the system, over 47 million more Americans will be accessing our health care system on a regular basis. How will an already overwhelmed system be able to accommodate a massive influx of patient visits by people who have delayed doctor visits due to lack of coverage? The root of this problem lies with our medical schools, which are not producing a sufficient number of graduates to meet this burgeoning need. Data from the American Academy of Family Physicians indicate that to keep up with the demand for primary care doctors, over the next decade the U.S. will need to add another 40,000 physicians to the existing 100,000. Rural areas will be particularly hard hit since these regions historically have fewer doctors to begin with.

An even larger issue impacting health care access is the question of undocumented immigrants. Currently, momentum seems tilted toward preventing them from securing public or private health insurance. If this opinion becomes part of the enacted reform legislation, our communities will be faced with a nightmarish public health scenario; namely, how will undocumented immigrants receive care while they are still here in the U.S.? Short of mass deportations, we are still left with the issue, leading some to advocate that the President must address immigration policy before health care policy.

Absent some miraculous policy shifts, what we are likely to see in the short term is a further socioeconomic divide in how health care is delivered. The poor and indigent will continue to use emergency departments and community health centers as a refuge of last resort, swelling the capacity of these health providers beyond the resources they need to meet demand. This trend will be particularly acute in states like California, Texas, and Arizona, which have large undocumented populations.

Those with financial resources will have more options for accessing a health provider. Suburban areas in particular will see a meteoric rise in boutique private physician practices, known as concierge medicine. Under this model, patients pay a flat monthly rate for 24/7 access to a primary care provider combined with catastrophic medical coverage and a health savings account, the latter being used for any out-of-pocket health care expenses. Many of these patients will also have access to home visits a throwback to the days when doctor’s made house calls.


The cost of care in America is a hot topic of debate these days. However geographic disparities in health care value are often overlooked. Michael Porter, a Harvard professor and author of the book Redefining Health Care: Creating Value-Based Competition on Results, has long stated that this value proposition should be the emphasis of any reform effort. Porter argues that significant improvements in the value of health care require a fundamental restructuring of our health care delivery model, not incremental improvements. He claims that valuebased provider competition for patients and referrals will be the main driver of meaningful health system change.

Evidence suggests that geographic distinctions in health care are beginning to take shape. The recently released 2009-10 Data Advantage Health Value Index study analyzing more than 4,500 general acute care hospitals nationwide found that America’s best hospital value is often in smaller towns, particularly those in midwestern states. Further, this care was predominantly provided by communitybased hospitals close to home. Topranked hospitals were found in geographically diverse locales such as Dotham, AL, Clarksburg, WV, Holland, MI, and WinstonSalem, NC. The topfive states for hospitals delivering high value were North Dakota, Iowa, Montana, South Dakota, and Maine.


According to a Kaiser Family Foundation study, premiums for family health coverage have more than doubled since 1999 from $5,791 in 1999 to $13, 375 in 2009. Employer-sponsored plans have seen their employee-paid premium amounts increase by 128%.

Viewed through a geographical lens, Kaiser reports that Utah has the lowest per capita health care costs in the nation, with residents spending $3,972, just a little more than Canada’s $3,912 and slightly less than France’s $4,056. Compare this with the U.S. average of $7,026. President Obama along with many health reform advocates often cite Salt Lake City-based Intermountain Healthcare as a model for costeffective, quality medical care. The secret to success for the largest healthcare system in the western region is a concept known as evidencebased medicine, where doctors make liberal use of scientific evidence regarding the effectiveness of treatments.

As cost concern debates continue, Federally Qualified Health Centers (FQHCs) will assume a more prominent role in our nations communities. The umbrella term for community health centers, public health centers, and tribal health facilities, these safety net providers capture a high percentage of underserved populations who would otherwise not have access to care. Thousands of FQHCs exist today and are the health delivery option of choice for millions of Americans. According to the National Association of Community Health Centers, between $9.9 billion and $17.6 billion in health savings a year are attributed to health center support in directing patients toward preventive and nonemergency room services.

A likely catalyst to reframe the health-care cost conversation is medical tourism. Also known as global medicine and health tourism, it refers to the popular practice of patients traveling across international borders to access health care at costs 50%-70% less than in the U.S. These expenses are often inclusive of airfare and hotel for both the patient and their families.

Procedures that are often performed by Americantrained, board-certified physicians include knee and hip replacements, cardiac surgery, dental surgery, and cosmetic surgeries, among others. Despite some concerns about regulatory and legal oversight issues, medical tourism continues to grow in popularity among Americans who otherwise not be able to afford the cost of care at their local provider.

It is no secret that commercial health insurers are jumping on this bandwagon, as domestic health care cost continue to climb unabated. The topfour commercial health insurers in the U.S. are pursuing pilot programs to determine the efficacy of overseas health care. Several small insurers as well as brokers are introducing travel options for growing numbers of employers many of whom are facing premium increases of 9% or more annually, according to the international consultancy PricewaterhouseCoopers.

Rogue initiatives like medical tourism certainly hold promise for spurring health care affordability. But encouraging Americans to take greater responsibility for their own health behaviors is the likely elixir for reining in costs.

Whats Next

It’s anyone’s guess as to where health reform is headed. A discussion to watch is state and regional differences in how health care services are being managed and delivered. It portends messy politics though in achieving comprehensive health reform.

Michael Scott is the president of Visions for Downtown America, Inc, an economic development firm supporting the growth and sustainability of downtown central-cities. He can be reached at