BELTON — To say that going to the doctor is a hassle for Bartlett resident Barbara Sandobal is putting it mildly.
“You have to budget half a tank of gas for a simple blood test,” said Sandobal, president of the Bartlett Area Chamber of Commerce. “We have no doctors here, nothing. It’s 25 miles one-way to the clinic. And people on fixed incomes can’t always afford the gas.”
Sandobal lives in an area that the U.S. Department of Health and Human services considers medically underserved.
“Medically underserved” is a designation that, according to Health and Human Services guidelines, is made by calculating the ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level and the percentage of the population age 65 or over.
All of the factors are calculated to obtain a score, ranging from 0 to 100, for the area. The lower the score, the more underserved the area is, and a ranking of 62 or less qualifies the area as underserved.
When South Bell County, which includes Bartlett, Holland, Salado, part of Belton and Killeen and unincorporated areas, was evaluated in March 2007, it was given a ranking of 57.
More than 140 of Texas’ 254 counties have at least one area that is considered medically underserved, according to figures from the Texas Department of State Health Services.
For the more than 3 million people who live in rural Texas, according to the state demographer’s office, getting access to health care is a daily struggle in terms of both time and money. And it has been for decades.
The Department of State Health Services began tracking the issue in 1975. While the total number of physicians in Texas has grown steadily over the years — from 2003 to 2013 the number of direct-care physicians alone grew by more than 11,000 — by and large those newly minted sawbones aren’t hanging out their shingles in small towns.
“Doctors go where the money is,” said Rita Kelley, department head of Bell County Indigent Health Services. “We’re trying to keep doctors in Texas, but we have trouble getting them to go to rural areas.”
Plan didn’t deliver
Over the last 30 years, the state repeatedly offered incentives to attract doctors to underserved areas. In 2009, the Legislature undertook a major revision of one of the state’s largest incentive mechanisms, the physician education loan repayment program.
The loan repayment program forgives student debt for doctors who practice in underserved areas. When it was created in 1985, it forgave up to $45,000 in debt.
With the passage of HB 2154, the bill authorizing the 2009 overhaul, the amount of forgivable debt was raised to $160,000.
A significant factor in the passage of HB 2154 was the medical lobby. In March 2009, the Texas Association of Community Health Centers launched Health Access for Texas, a campaign designed to pressure the Legislature into passing a slate of physician compensation-related bills, including HB 2154.
As it was launched, medical organizations such as the Texas Association of Community Health Centers said within four years the updated program would bring 900 new physicians to underserved areas of Texas.
The program never got anywhere near the projected numbers.
Figures from the Texas Higher Education Coordinating Board, the state agency overseeing the program, show that in the five years since the loan repayment program was rebooted, 267 doctors, about one-third of the promised number, moved to underserved areas.
Jose Camacho, executive director of the Association of Community Health Centers, said the problem isn’t that the program’s effectiveness was oversold; it’s that it was underfunded.
A powerless constituency
Camacho’s assessment of the early effectiveness is debatable. In fiscal year 2010, the program attracted only 63 physicians, not the 225 advertised, but the cuts in 2011 is a historic record.
“It’s a great program, but it’s only going to work as well as it’s funded,” said Stephen Brotherton, president of the Texas Medical Association, “and the Legislature gutted the funding in 2011.”
In 2011, Texas faced a massive budget shortfall, estimated at more than $20 billion, which prompted spending cuts.
No funds were appropriated for the loan repayment program, said state Sen. Juan “Chuy” Hinojosa, D-McAllen, who sponsored the Senate version of HB 2154.
“It was pretty disappointing,” Hinojosa said.
While the Legislature did restore partial funding to the program in the last session, it is still a long way from its goals.