A lot of rural hospitals (and indeed many healthcare providers) are really poorly managed as businesses. This has been exacerbated by the labor shortage in healthcare, which is one of the industries that immigration alone can save at this point. (Hi Flint: https://withflint.com/)
Scarce talent is being recruited away by higher paying providers in urban centers, which is why you see occasional headlines about the skyrocketing pay of travel nurses. COVID made this more acute, and while that crisis has faded, the secular trends have not gone away, notably America's demographic aging.
A sub-issue is that even when the hospital stays open, you often get poor care. My family has been on the receiving end of that, with my aunt dying prematurely because her cancer was missed by a subpar rural GP.
The reason for the scarcity of talent/ doctors is due to a regulation change in 1983/1996 that wasn't adjusted until last year that was restricting the number of residency spots for doctors in the US.
*Also note this has been slightly fixed with an increase of residency spots, but still puts the US in position to have fewer doctors per person than almost all other developed countries.
That may explain the overall lack of doctors in the US but seems irrelevant to this thread about rural healthcare.
All you have to do is look at other countries and see the same issue playing out. Germany, Vietnam, and Australia are all very different from the US, and from one another, and all have issues with rural health care.
The reality is that low populations make it hard to provide any service and most of the "first world infrastructure" they do have is provided by federal or state/provincial government (i.e. not their own tax base). They aren't attractive places to live for many professionals, who usually trained in bigger cities and are used to small comforts like being able to eat a variety of cuisines or seeing live events (sports, music, drama) or having good schools for their children. The cost structure and (relatively) low demand affect the financial side of the equation. Etc etc.
Many countries allow "foreign doctors" provided they do some kind of provincial work (think of the old comedy series Northern Exposure) but that hasn't exactly proven to be a panacea.
Why does the federal government need to pay for every single residency? Ok, maybe they messed up in 1983/96—no other entity in the entire nation was capable of picking up any of the slack?
This is beyond the scope of my knowledge, but what I can say is that the original issue in the 90s arose from a fear of too many doctors coupled with too much spending on said doctors which resulted in multiple regulatory changes to prevent this outcome.
I never got this either. Residents, from my understanding, are paid poorly. Hospitals charge immense amounts of money. Surely they can squeeze a few residents in there without begging the government for money.
Residents are poorly paid, but residency programs are expensive to operate and expand. The non-profit and public sector teaching hospitals which operate most such programs are generally doing better than small rural hospitals but they're still in a precarious state. They take losses treating a lot of uninsured and Medicare/Medicaid patients.
Residencies lose money. The doctors that teach in them generally do not enjoy it(source my father who is a doctor and chairs a residency) and need to be paid extra to participate. There would be close to none without the federal subsidies.
The federal government has a lot of money. So does the California government. So does the San Francisco government. So does the Bill and Melinda Gates Foundation. So does Harvard University. So does Amazon. So does UnitedHealth Group. So does NY Presbyterian.
I reiterate: Why does the federal government need to pay for every single residency?
Or rather, misaligned incentives. If they aren't paying for residencies today, there's no reason to believe they'll magically do so tomorrow. Also, if a state decides to do so, that still leaves every other state with insufficient funding for residencies.
There’s a bunch of people that think the federal government should fund more residencies. Some of them raised money, hired lobbyists, made slick websites etc. Others are on websites like this talking up the issue.
They don’t seem to be getting anywhere. Looking at the current state of Congress and the trend line I’m not super optimistic they will pass any sort of “common sense” laws in any area anytime soon.
What I’m suggesting then, is perhaps all these advocates should find some other trees to bark up. Maybe they’ll get no where, maybe they’ll be pleasantly surprised.
Or they can just keep doing what they are doing. I don’t especially care.
Which other entity would you suggest? Residency programs mostly run in non-profit or state government teaching hospitals. They are already financially struggling.
The “non-profit” hospital systems* by me are neither non-profit, nor struggling. They are distributing their large profits to their de facto owners—the executives.
* Systems not hospitals. These groups are gobbling up the entire industry. Hospitals are only a part of their diversified portfolio of businesses.
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What about the universities with the medical schools? How many of them are sitting on giant endowments?
It does not restrict the number of residencies, but the number of federally-funded ones. And for some propaganda reason that is always presented as a cap on residencies, not on their funding. With for-profit healthcare why can’t private market step in? I guess it’s not profitable. Who could have guessed.
How does one fix expensive education and a cartel limiting the number of qualified doctors with immigration?
Why would I, a qualified and respected doctor in my country want to move to the US (or Canada) if it involves going through 4 more years of bullshit just to get re-qualified for a system that adds even more red-tape, expenses, and middle-men between me and the patient?
I know, you're probably saying, "oh, but so many people have" - but hey, that was in the past. Unless my country is getting bombed to hell, I'm probably making a damn good living where I am, because, guess what? There's a shortage of doctors everywhere outside of Cuba!
It doesn't help doctors since they have to pass the same residence process before they can practice in the United States but lots of countries like Mexico and the Philippines have nursing degrees that are valid in the US as long as they pass the NCLEX-RN exam. Each university's program is evaluated individually but it's a standardized process.
Once they're here they can follow the nurse practitioner process which allows them to do many of the same things as doctors.
You don't. Immigration is not a "solves all problems" solution. Its a "drive down wages so that we live in a 3rd world country like the immigrants we are paying" solution.
I used to be a big libertarian proponent for immigration and now I've become the complete opposite after seeing how much money wall street (and almost exclusively corporate special interests) puts into increasing immigration.
can you be more specific in how letting qualified doctors and engineers from other countries (doesn't even have to be third world, a lot of british doctors would move here given their starting salary of 30k) will turn us into a third world country?
also, the wage argument doesn't make sense because rural doctors earn more than urban doctors due to the low desirability of the location, and despite med schools specifically selecting for students who are willing to become rural doctors, they still cannot find enough doctors to fill those spots.
(https://medrecruit.medworld.com/articles/how-much-do-rural-d...)
its also concerning that the reason you decided to oppose immigration was not for a tangible reason, but because wall street supports it. seems like contrarianism run amok. did you become a communist because wall street supports capitalism?
Immigrants from poorer countries will do anything for a buck. It becomes a race to the bottom. As long as conditions here don't get worse than where they came from they'll be happy. But for us, its just down, down down in terms of quality of living.
If rural hospitals need to pay doctors even more than so be it. I want that job going to an American.
Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?
"Immigrants from poorer countries will do anything for a buck. It becomes a race to the bottom. As long as conditions here don't get worse than where they came from they'll be happy. But for us, its just down, down down in terms of quality of living."
would you be open to mass immigration from europe and east asia, in that case? some of the countries have even higher standards of living, so logically those immigrants will demand better and raise our standards of living. Also, most cities like san diego, miami, dallas, atlanta etc have all become safer, cleaner, and the QoL has increased dramatically from 30-40 years ago. These cities have all become increasingly immigrant populated relative to 30-40 years ago, many of these immigrants coming from latin america or asia.
"If rural hospitals need to pay doctors even more than so be it. I want that job going to an American."
the crux of the issue is that there literally aren't enough american doctors. med schools giving recruitment preferences to doctors willing to work in rural areas + a much higher salary + a much lower COL still aren't enough to attract american doctors there. I don't know what magical solution you have to make thesecommunities desirable destinations but I am all ears.
"Is it concerning because I don't care about what society thinks? Is it concerning that I don't care about getting an attaboy (e.g. karma) for towing society's latest groupthink?"
no? There are many valid arguments to heavily restrict immigration, largely based on middle class incomes and cultural attrition, i just don't see how any of those apply to doctors in rural areas. and i was responding to how you openly admitted that you dislike it because wall street likes it. seems like a bad way to approach policy!
It's not that straightforward. There is a shortage of CNAs, RNs, and LPNs willing to work in current conditions for current pay. Lower patient ratios and higher pay would naturally bring more labor into the healthcare labor pool. If you're going to import healthcare labor and still subject them to the existing suck that is US healthcare labor, that is not sustainable.
(light edits made to capture nuance vs absolutes, previous comment version started with "there is no healthcare labor shortage", which is not accurate)
Oh, it's perfectly sustainable. It allows wealthy hospital shareholders to continue reaping huge profits without having to improve conditions, wages, or staffing ratios. Unlike America, which has a finite supply of people willing to be nurses, we can simply hire immigrant nurses and replace them as they burn out.
You're right to an extent, but there legitimately is a shortage of physicians. The supply can't expand to meet demand regardless of working conditions and pay because Congress has capped funding for residency program slots.
The baby boomer generation has more chronic health problems than the generation before them. And, there are more of them. This leads to more health care services needed.
Yet, where I live the nursing schools have not expanded the number of graduates per year.
Supply and demand. Demand is going up. Supply is staying constant.
It's usually less of a zero-sum game than we might expect.
Also some people have a plan to leave their country either way, so giving them opportunities in fields that might be useful for everyone should be a net positive.
Other countries subsidizing education and the more developed ones reaping the results is very much a zero-sum game. Immigrant myself, I'm all for people getting better lives, however if you're talking churning 10-20% of a small country's doctors or nurses to the US it would be catastrophic.
There's more nuance, in that it's not just a one-way transfer, and education is not just subsidized by the country.
On the former, Phillipines are sailant example of sending people abroad to get goods and money back, but this happens at some scale for all other countries with a significant emigration. The money fed back in the original country is usually not something to sneeze at.
The other part is, education benefits everyone beyond the single individuals. Having a strong enough education programs that opens the door to move to other countries with strong requirements is an asset that also benefits the origin country. In most countries only a small portion will go abroad, so improving the overall level of students stays important, and the bigger the pool the more you have inter-student emulation + economy of scale effect.
Also the monney spent by the country into education is not just for single children and has a global societal effect.
All in all, IMHO it's not a black and white as "that kid wasted our tax dollars by going abroad"
Scarce talent is being recruited away by higher paying providers in urban centers, which is why you see occasional headlines about the skyrocketing pay of travel nurses. COVID made this more acute, and while that crisis has faded, the secular trends have not gone away, notably America's demographic aging.
A sub-issue is that even when the hospital stays open, you often get poor care. My family has been on the receiving end of that, with my aunt dying prematurely because her cancer was missed by a subpar rural GP.