4.3: Geography of Care

The geographical variation in death and disease can also be attributed to the geography of health care. Wealth explains most of the variation in access to quality health care globally and nationally. The health of poor people everywhere suffers from multiple burdens, many of which begin well before a person is born. Impoverished pregnant women may be malnourished and unable to afford the costs associated with proper pre-natal childcare, especially where the government does not provide health care. Poor women also tend to have babies born prematurely, and premature babies often suffer from low birth weight, which in turn invites numerous additional ill-health outcomes, most notably infant death. Poor children often continue to suffer from poor diets and an inability to access regular, high-quality health care throughout their lives which shortens their lives and reduces their capacity to be productive citizens. Many of the poorest areas in the United States have high percentages of physically or mentally disabled citizens.

Access to Medical Facilities

Poor people are not attractive customers for profit-driven health care providers. Poor people, especially before the Affordable Care Act (Obamacare), frequently had little means to obtain health insurance outside of the government-run Medicaid program. This fact limits health care options for millions of people in the United States. As a result, uninsured people tend to wait until they are very ill to see a doctor, often requiring a visit to a hospital’s emergency room where federal law requires the provision of medical care, regardless of the patient’s ability to pay. The government partially reimburses hospitals for the costs of emergency room care, but much of the cost of caring for the indigent is paid for by charities and/or passed on to those with insurance – another example of an economic externality. Hospitals that serve too many indigent patients risk going out of business. As a result, doctors and hospitals avoid many of the poorest areas of the United States, favoring places where well-insured patients generate bigger profits. https://arcg.is/zTXbn

Figure 4-20: US County Map: Orange indicates medically underserved regions, blue indicates medically underserved populations. Source: HRSA – Interactive Map *or* ArcGIS Online Interactive Map

Geographers sometimes call regions without medical facilities medical deserts. Most medical deserts are in poor rural areas, but a few inner-city areas in America’s largest cities also suffer from limited access to health care provision. The passage of the Affordable Care Act was intended to shrink or halt the expansion of medical deserts in most of the US, but the expansion of medical deserts continues in states where politically conservative politicians opposed to Obamacare prevented their state from funding expansion of Medicaid programs for those who were both too poor to afford private insurance, but not poor enough to qualify for Medicaid. Multiple challenges to Obamacare, especially since the election of Donald Trump have reversed some of the gains made from 2010-2019. An estimated 10-15 million additional uninsured people, largely living in poor, and politically conservative regions, has expanded the threat of medical desertification.

Geographers also analyze health care access at very local scales. Perhaps the most closely scrutinized region has been Los Angeles’ “South Central” neighborhood. As far back as the 1965 Watt’s Rebellion, black residents of Los Angeles have complained about poor access to doctors and hospitals. Government officials, in an attempt to shorten the distance residents of South Central LA had to travel for medical care, opened the King-Drew Medical Center in the early 1970s. However, after years of shoddy health care provision by the staff at King Drew, the facility was closed in 2007, including its very busy trauma center. The closure angered nearby residents who would have to be transported to more distant emergency rooms for emergency treatment. Although it was controversial, most residents of South LA have reasonably good access to trauma care compared to residents of many areas of the US. Indeed, all Los Angelenos have reasonably good access to trauma centers and hospitals.

Figure 4-21: Maps. On the left is a US map showing one-hour transport distances to trauma centers. Los Angeles area trauma centers and a 45-minute ambulance ride are mapped (right). Source: Traumamaps.org