Access to high quality, affordable health care

by Becki Gray, John Locke Foundation and NC SPIN panelist, May 3, 2018.

North Carolina ranks 44^thin the nation in access to health care. That’s an average of access across the state. When you consider that we have great access in some parts of the state – those close to metropolitan areas and teaching hospitals in Charlotte-Mecklenburg, the Triad, and Triangle – that overall ranking is actually misleading. Access is especially poor in rural parts of the state.

In North Carolina, 20 counties do not have a pediatrician, 26 counties do not have an OB-GYN, and 32 are without a psychiatrist. Three counties have not had a dentist for the past 10 years, and 70 counties in North Carolina have been designated as dental health professional shortage areas. North Carolina consistently ranks 47th among the 50 states in terms of dentist-to-population ratio.  Seventy of the 80 rural counties in North Carolina are currently designated “medical deserts” for their lack of primary care availability.

When there’s less access to health care, there are poorer health outcomes, people don’t get diagnoses and treatment early, and the population experiences persistently higher mortality rates. When there’s less health care infrastructure, a downward spiral occurs. Fewer doctors want to practice in underserved areas, there’s less care, costs go up, and healthy people don’t access care in early stages of illness. Sick people get sicker. When less health care is available in an area, people don’t want to move there, fewer businesses expand and relocate, there are fewer jobs, and all this results in higher rates of poverty. People get sicker, outcomes are worse, care is less accessible, and at a higher cost.

We don’t have a physician shortage; we have an allocation problem. It’s not a matter of supply but of distribution. Most providers cluster in wealthier, more culturally diverse urban areas. Of the 434 medical school graduates in North Carolina in 2011, only 1.6 percent (seven graduates) are currently providing primary health care in rural areas. Where to practice and live is a choice doctors make. But it goes further than doctor distribution.

There are also real economic costs linked to a lack of health care.New entrepreneurs need access to health care in order to offset the risk of opening their own business and to attract and retain workers. A community that doesn’t have a good health care system isn’t going to get to first base in recruiting new companies. To recruit good workers, employers must be able to ensure access to quality health care at an affordable price.

Now I’m not suggesting a new government program or set of regulations controlling where doctors can live and practice, exerting even more government control of our health care system.  I’m suggesting that we do the opposite – that we remove the legal handcuffs that regulations have imposed on our health care providers. I propose that we solve the problem by empowering individuals, using the power of enterprise and free markets, not government regulations.

Four policy changes can be made that would transform our health care system. These are innovative ideas that would not require new government programs and massive taxpayer funding.

Telemedicine allows interaction between patients and health care providers using technology instead of face-to-face visits.  Doctors can monitor and treat patients from a distance, saving time and money. Technology has been used in overcrowded emergency rooms, accessing experts located elsewhere to stabilize stroke victims and save lives.

Exploring new models of health care delivery is gaining acceptance from both doctors and patients. Direct primary care offers patients 24/7 access to their doctor without the constraints and complications of insurance. Paying a monthly fee, fees for services rendered, and a high deductible insurance plan covers medical needs and restores the traditional doctor/patient relationship many had found missing. There are currently more than 30 direct primary care physicians in North Carolina. Union County offered direct primary care as an option for its employees. In addition to great satisfaction with the plan, the county saved over $1 million in health care costs in the first year. 

One way to expand care is to allow medical providers to practice within their full scope of training. Remove barriers for professionals to do what they do and allow them to work. Twenty-two states have removed their requirement that a physician supervise nurse practitioners. Fourteen states have moved to “full practice authority” for advanced-practice registered nurses, nurse practitioners, and nurse anesthetists since 2010.  When Arizona removed its requirement of physician supervision of nurse practitioners, the number of nurse practitioners serving rural areas jumped by 73 percent within five years. Removing government handcuffs from dental hygienists and allowing dental therapists and midwives to provide basic care will increase access and bring down costs when preventive and management measures can replace emergency care for serious illnesses that have been neglected.

North Carolina needs to repeal certificate-of-need laws, as 15 other states have done. Qualified doctors and medical providers must get government approval before they expand or build their practices, purchase new equipment, offer different services, or open new facilities. The process is expensive and time-consuming. It is particularly difficult for smaller practitioners. North Carolina has the fourth most restrictive certificate-of-need laws in the country. Numerous studies confirm what common sense tells us: Certificate-of-need laws stifle competition, drive up costs, and limit access to care. 

Major tax cuts, limiting the growth and scope of government, paying down debt, building savings reserves, and massive regulatory reform have propelled North Carolina to a No. 1 ranking in Forbes Magazineas the most business-friendly state in the country. In the Tax Foundation’s business tax climate index, North Carolina has climbed from 44^thin the nation in 2010 to 11^thtoday. These efforts have achieved a tremendous economic benefit for our state. A total of $5 billion has been returned to taxpayers, over 444,000 net new jobs have been created, businesses are growing, and more businesses have been created and are profitable. Unemployment has been cut in half since 2011. The next frontier of North Carolina’s reform efforts must be medical. Not only will it create more economic benefits for our citizens. More important, it will save thousands of lives. High quality, accessible, lower-cost health care is literally a matter of life and death.