Most Missouri doctors work in densely populated communities, while areas needing physicians appear unable to attract them. Although health care issues fill our headlines, the problem of distribution receives little press coverage. Our state suffers from a unique health care disparity problem, one of geographic distribution. Elsewhere in America, it has been common for people to migrate to the cities and their suburbs, while in Missouri many prefer to live in rural areas. Today, about 27 percent of our state’s residents live in rural locations.

Previously, people thought the physician distribution problem would be resolved by economic factors alone, and suggested there would be a diffusion of doctors from urban to rural communities. But that did not occur. This may be attributable to the problem that most of the Missourians without health insurance live in rural areas. A 2004 state survey found that rural regions had the largest populations without health insurance, and few doctors choose to work where most people have no health insurance.

At one time, people thought the distribution disparity arose from physicians preferring to be near other doctors, in order to benefit from professional synergism, such as sharing emergency calls. However, another factor has been found: the risk of lower earnings in rural medical practices — a disincentive that keeps physicians from choosing those locations.

In response to this problem, the federal government started the National Health Service Corps (NHSC) to establish financial incentives that would bring doctors to areas with a physician shortage. Congress then established the Area Health Education Centers (AHEC) program, designed to retain health professionals in these locations.

Neither program, however, has satisfied Missouri’s needs. In spite of these government efforts, more than 18.6 percent of Missourians live in areas that are underserved by physicians, and more than 60 Missouri counties are identified as health care professional shortage areas. Last year, Missouri became the 10th-worst state in terms of the doctor/citizen ratio.

Why does this problem continue? In 1991, there were 10,095 physicians working in our state. Since then, the number has grown, and by 2001 there were 12,565. At the same time, however, the average physician age has increased. During that 10-year interval, the number of physicians under age 45 decreased by 25 percent, and now most rural Missouri surgeons are looking to retire. As a result, many Missourians do not have access to the health care they need.

How to respond remains uncertain, although a recent innovation addresses this issue. Missouri Southern University and the Kansas City University of Medicine have united to build a medical education program in Joplin. In an example of a group of citizens responding to their own needs, that community is developing a school to supply them with doctors. With this new program, another 100 physicians will graduate each year from the Joplin location. No one knows whether those graduates will remain in the area, but after four years, some will have local ties. Others, though, will look elsewhere. To keep them, incentives will be needed.

One approach might be to underwrite medical student loans that will connect the students to a local service obligation. Vermont initiated such a practice, and it has done well. There, new physicians that accept such loans have an obligation to practice in areas where there is a physician undersupply. A similar program already exists in Missouri, but it has had such limited publicity that most medical students and physicians are not aware of it.

There may be other and/or better incentive programs. It is up to your ingenuity, and that of your community, to develop them.

Today’s Post-Dispatch has the history behind the famous 1876 split between St. Louis County and city. This coincides nicely with an opinion piece that the Show-Me Institute just released, about St. Louis city rejoining the county. I discussed both this op-ed and the overall subject it addresses on the McGraw Show a few weeks ago, on The Big 550. (Scroll down to 8/3/09.) It’s always nice when things tie together so well.

I won’t add any more here, because it would just be repeating what I wrote in the op-ed and said during the radio interview, both of which you should all go read and listen to without delay.

It turns out I spoke too soon when I said beer companies enjoy so much freedom to advertise and market their products in the United States. The news reported in this Wall Street Journal article is appalling. All Anheuser-Busch did was change the colors of its cans to match college teams’ colors, and now everyone, from the FTC to the colleges themselves, is in an uproar.

The colleges allege trademark infringement. The beer cans don’t feature any mascots or logos, though, so I don’t see how Anheuser-Busch could be in violation of trademark. Surely, these schools don’t have a monopoly on color combinations like blue and yellow.

Regarding marketing to underage students: It’s true that most college freshman and sophomores aren’t old enough to drink, but what about the juniors, seniors, graduate students, and faculty? Are they off-limits, too?

The FTC would have a weak legal case because of a concept called “free speech.” The government can’t forbid a company to use a combination of two colors on a package. However, that doesn’t deter an FTC lawyer from harassing Anheuser-Busch:

“We would certainly hope that something like this never happens again,” she said.

School districts will tell you it’s wrong to make decisions based on test scores — unless you conclude that textbooks are useless:

The district usually replaces the science textbooks every six years. This year, it would have cost the district $610,000 to buy new ones.

But district officials found they were wasting money on the books. When they looked at standardized test scores in science, they found that classrooms with the highest scores never touched the textbooks.

Districts don’t systematically use test scores to evaluate teachers, which makes the textbook evidence suspect. A correlation between textbook-free classrooms and higher scores doesn’t necessarily mean that textbooks lower scores. It might be that better teachers choose hands-on projects, but those teachers would improve achievement no matter which curriculum they used. If the textbooks used previously were inadequate, it could be that better textbooks would boost scores even more than exploratory activities. It’s also possible that the hands-on work is superior to textbooks, but that teachers who didn’t adopt the approach voluntarily won’t use it well when the district mandates it for all classrooms.

This should not be taken as a criticism of the mobile science lab described in the article, which sounds like a worthwhile addition to the curriculum. I just object to the arbitrary use of test scores to advance certain popular programs, like hands-on science, but not controversial policies like merit pay.

Below is the full text of a comment from a blog post over at the Post-Dispatch’s Political Fix blog. It demands a response from anyone who is not content with living in servitude to the government. My comments follow each quoted portion.

I assume this piece was not original to the Post, but it may have been. I remember about 15 years ago when a state rep from south Saint Louis County wrote a similarly themed article for the Post, and then got in a lot of (political) trouble when it turned out she had just copied it from somewhere else. I remember her name, but don’t feel like printing it. She did lose her next election, if I recall correctly. (All that stuff predated the web by a few years, so no free links are available.)

Not everything he (or she) writes here is crazy or wrong, so feel free to take my lack of comment on certain areas as being along the lines of agreement in those instances:

Dear Tea Party Members:

This morning I was awoken by my alarm clock powered by electricity generated by the public power monopoly, Ameren UE, regulated by the US Department of Energy.

All true, as it goes, but are you really that dependent on the government to get you out of bed in the morning? And didn’t the alarm clock get built in the first place by the mechanics of the free market?

I then took a shower in the clean water provided by the municipal water utility, Missouri American Water.

This is the first flat-out error: Missouri-American is a regulated, private company, not a municipal water utility.

The water was heated by the public natural gas monopoly, Laclede Gas,

Laclede Gas is a private company.

and disposed of by the the municipal sewer utility, Metropolitian Sewer District of St. Louis.

A government entity — ask Tom Sullivan about them.

After that, I turned on the TV to one of the Federal Communication Commission regulated channels to see what the National Weather Service of the National Oceanographic and Atmospheric Administration determined the weather was going to be like using satellites designed, built, and launched by the National Aeronautics and Space Administration.

This totally ignores the role that private companies and people played in all of this, and ignores the fundamental question of whether this regulation is necessary. I can guarantee you the television needs of Americans would be met just fine without government regulation.

I watched this while eating my breakfast of US Department of Agriculture inspected food and taking the drugs which have been determined as safe by the Food and Drug Administration.

This is all true, and a legitimate role for various levels of government, but let’s not pretend that nobody in America was able to feed their families before the government got involved. A nation of farmers fed itself just fine.

At the appropriate time as regulated by the US Congress and kept accurate by the National Institute of Standards and Technology and the US Naval Observatory,

Does the author really think people could not tell time before the government got involved?

I get into my National Highway Traffic Safety Administration approved automobile and set out to work on the roads built by the local, state, and federal departments of transportation,

The private provision of highways is very common in other countries.

possibly stopping to purchase additional fuel of a quality level determined by the Environmental Protection Agency, using legal tender issued by the Federal Reserve Bank. On the way out the door I deposit any mail I have to be sent out via the US Postal Service.

The Post Office versus FedEx and UPS? Enough said.

If I had kids, I would probably drop them off at the nearby public school funded by the state and federal Department of Education.

Many Americans choose private education for their children for a number of reasons, the failure of certain public school systems among them. Clearly, there are many excellent public school systems as well.

At lunch time, I pick up a bite to eat at a nearby restaurant that has been inspected by the local department of health which enforces state and federal guidelines for food safety and workplace safety. I then return to my cubical where I listen to the local FCC regulated radio station

As with television, I will guarantee you that, beyond distributing the channel spectrum as a common good, government involvement is not necessary for radio to operate, at all.

as I work on a computer that has been certified by the Consumer Products Safety Comission to be safe and compliant with FCC Part 15B regulations.

The computer industry has grown as it has during the past 40 years because of private markets, not government involvement.

Sometimes instead of work, I go on a business trip and use an airplane inspected by the Nation Transportation Safety Bureau to travel. But first I have to take off my shoes and anything metal as a walk through the the inspection station set up by the Transportation Safety Adminstration.

Watching grandpa get a body cavity inspection because he shares a nickname with a terrorist is not an argument for government success.

After checking the weather with the National Weather Service, the Federal Aviation Adminstration gives the all clear for the airplane taxi off the tarmac and to take off.

Then, after spending another day not being maimed or killed at work thanks to the workplace regulations imposed by the US Department of Labor and the Occupational Safety and Health Administration, I drive back to my house which has not burned down in my absence because of the state and local building codes

People CAN build things on their own, you know.

and the fire marshall’s inspection, and which has not been plundered of all its valuables thanks to the local police department.

It’s a sad view of society that assumes we would all descend into chaos without government force — perhaps a true view, but still a sad one. I tend to think people cooperate in many more ways without government coercion than the author does.

At home, I can call up my grandparents on a cellular telephone that is FCC Part 15B complaint and designated on a frequency regulated by the National Telecomunication and Information Administration.

As with computers, the telecommunications revolution is attributable far more to private initiative than to government control and regulation.

I then log onto the Internet which was developed by the Defense Advanced Research Projects Administration, an agency of the Department of Defense which is the parent agency of the US Army, Navy, Air Force, and Marine Corps who are defending our country so that I can enjoy my freedom to post on Freerepublic and Fox News forums about how SOCIALISM in medicine is BAD because the government can’t do anything right.

End of letter. Many of the points the writer makes are valid to varying degrees, but he discounts or ignores the role individuals and private actors played in many of the advancements he credits to government. What is also missing is any even remote debate over whether or not these things are the proper role of government as set by our Constitution. As it stands, the letter makes Americans sound like a nation of people who could not blow their nose (the closest to a clean scatological reference I could think of) without government involvement and approval.

Seriously, you thank the government for helping you get out of bed in the morning? That is not the type of life I want to live and not the type of country I want the United States to become.

It was short-lived, and it could have been worse. Yes, I thought it was a bad program, but I wouldn’t go so far as Cato’s Chris Edwards to say it was the “dumbest program ever.” Better to give away something for next to nothing than to give away something for countless calculations, changes in behavior, and misplaced investments. (If you’d like an example of such a program, look at the federal tax code!)

In some ways, the idea behind Cash for Clunkers was similar to the rationale for sales tax holidays. Both are intended to spur economic activity by giving consumers an incentive to spend on targeted items. Instead, each diverts spending from better uses, without generating new wealth.

To learn more about Cash for Clunkers, check out the entire post by Chris Edwards. For a mathematical analysis of the program’s effect on carbon emissions, see Matthew Kahn’s August 12 post.

This middle-class protest song makes “Mad in America” sound like lyric opera.

When all taxpayers have to chip in to keep your family farm going, it’s not a family farm anymore; it’s a collective farm. Family farms are quickly becoming a thing of the past. When the state steps in to “preserve” them, it actually transforms once-viable enterprises into repositories for tax dollars.

Statements like this make it clear that pouring money into small farms is a losing proposition:

“Right now it costs more to produce milk than you get paid,” Letterman said.

It’s not unusual to see some ignominious mention of SLPS in newspaper articles about education. The reference goes something like this: “Districts across the country are facing problems, including the Saint Louis Public Schools, which lost accreditation and blah blah blah …”

This Wall Street Journal article is no exception:

Perhaps the boldest marketing push is in St. Louis. The urban district’s enrollment has plunged 40% in the past decade because of students moving to charter schools and suburban districts. The school district has been through eight superintendents in 10 years and lost its state accreditation. It faces a $53 million deficit and recently closed 14 schools.

But administrators have set aside $1 million for pay for publicity that may include bragging about a top-ranked high school and magnet programs in culinary arts, aeronautics and international studies.

I’ve criticized SLPS in the past for obsessing about logos and bashing charter schools. However, this time around SLPS has good reason for marketing. SLPS has started new programs, like a virtual school and choice schools; it has to tell people about them, or no one will know they exist.

The more innovations SLPS comes up with, the more effective its advertising will be in bringing students back to the district.

This is one of those topics with a good chance of starting an argument, which would be swell fun for everyone. In the current debate over our health care system, to which the Show-Me Institute contributed a terrific paper to yesterday, one of the proposals put out there is tort reform. Indeed, our study states among its seven recommendations of how to improve our health care system:

• Reform tort liability laws.
  Defensive medicine needlessly drives up medical costs and creates an adversarial relationship between doctors and patients.

Now, to be clear, this is the last of the seven recommendations and the least discussed within the paper, but how do they mean for it to apply? This exact issue is being discussed all over the web. It also appeared in that great op-ed from the Whole Foods CEO that I linked to yesterday.

The health care bills being discussed are, as you all know, part of a federal issue that has tremendous effects on the states. But, because it is for the most part a federal issue, I’ll stick with how tort reform might be implemented nationally. I fully support tort/malpractice reforms in federal courts. But only a very small percentage of malpractice claims are filed in federal court — usually claims against a veterans hospital, or something like that. The vast majority of malpractice cases occur in state courts, and just four years ago Missouri passed greatly needed comprehensive changes to the state’s malpractice system.

So, are supporters of tort/malpractice reform talking about just changing the malpractice system at the federal level, which would probably be a good thing but would only affect a very low percentage of total cases filed? Are they talking about encouraging states to reform their own malpractice laws, which Missouri has already done very successfully and which I fully supported at the time and still do? Or — stay with me, here — are people who generally support states’ rights arguing in this instance for changing the law so that tighter federal laws would replace and overrule state laws in malpractice cases? I realize that it is incomprehensible that someone, especially a politician, would generally support doing things one way but change that opinion in an instance where it would work against you. (Please note dripping sarcasm.) So, which of the three is it?

I have to fear it is the latter, which is also the only one of the three possibilities I don’t support. Civil tort laws have long been the province of the states (I’ll stand corrected by any lawyers in the audience). Just because a federal takeover/usurpation in this instance might fall along the lines of something I support in general (tighter malpractice laws) does not mean I am going to give up on the 10th Amendment.

Missouri succeeded in making significant improvements to how our system deals with civil justice and malpractice a few years ago. It is my hope that Illinois will also do so soon. However, this is still something for the states to determine, rather than the federal government.

The Illinois boy with autism who I wrote about the other day will be allowed to bring his service dog to school, at least for a short time after the district discusses accommodations and before a full court hearing takes place.

I’m happy that the dog and boy will stay together, and I’m also glad that some of the district’s infuriating arguments were disregarded. The district claims the dog is not a true service dog because he isn’t listed in the boy’s Individual Education Plan (IEP). But the boy’s doctors said he should get a dog, and the dog was specially trained for several thousand dollars, paid for by the parents — that sounds like a service dog to me.

IEP’s can’t be as comprehensive as full medical evaluations; they’re basically lists of learning goals, and shouldn’t override doctors’ orders. And, because the district doesn’t want the dog in class, of course they wouldn’t recommend a dog in an IEP. You can’t conclude that the boy doesn’t need the dog just because the district left dogs out of the document.

This statement by the district Superintendent is misleading:

“If 230 students were to bring animals, it would be catastrophic to the degree it would be uncontrollable and very unhealthy to the students,” Settles said.

We’re not talking about pets brought for show and tell, but animals (usually dogs; I don’t know which other animals the district is expecting) that help children cope with serious medical problems. Dogs have to go through a lot of screening and training before they are given to patients. “Uncontrollable” animals don’t make the cut. I should hope the district would not advance similar arguments against a service dog used because of epilepsy or vision impairment. Autism deserves equal consideration.

Although the judge issued an injunction in the boy’s favor, I’m standing by my assertion that he would be better off with tuition tax credits. No one should have to attend a school that resents his service dog and that fought hard in court to exclude it.

Including Cash for Clunkers. This sentence sums up the experience:

President Barack Obama said in an interview Thursday that the program has been “successful beyond anybody’s imagination” but dealers were overwhelmed by the response of consumers.

Giving out free money (or paying above the market rate, which amounts to the same thing) is a wildly popular policy. No one should be surprised by consumers’ robust response to the opportunity to get something (cash) for nothing (a clunker, by the program’s own admission).

It’s strange to call a program “successful” when it did little more than squander wealth — and so quickly that even Washington politicians realized it couldn’t continue.

Although Cash for Clunkers will drive into the sunset on Monday, the idea lives on in a multitude of other policies that offer attractive payment in exchange for ubiquitous antiques. Like gun buybacks, for example.