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.

(2) comments


A primary reason for the lack of rural doctors has historically been the medical school application process. While in college I interfaced with many pre med students who took "classes" for the application. They, like I, were astounded on some of the answers that would be positively considered. Instead of answering that they wanted to help people and be assets to the community, the more acceptable response was to the effect "I want to make a lot of money and have a lot of prestige."

Another problem is that doctors often have young wives who prefer the city's social and economic advantages. In discussions with young interns, especially single ones, I would tell them, "If you want immediate acceptance; immediate prominence; immediate respect; immediate credit, etc. go to a small town. You can marry the town's best prospect; hold any civic office you want, and on and on." Very few listened.

For years I have encouraged the utilization of nurse practitioners in such underserved areas. A well trained nurse can handle most medical situations as well as - and often better than many institutional physicians such as those that are increasingly gravitating to hospitals and healthcare organizations. Those nurse practitioners I have known are more caring, more considerate, more objective, and more cautious as well. Their required physician oversight gives another layer of safety, and they know their limitations. They may well be the answer to the "looming physician shortage."

The areas listed in this article should get together and actively solicit a nurse practitioner or two to service their populace. They will get better, more immediate care, and their medical professional will be a member of the community. For a prime working example, they might want to send a committee north to the little town of Groesbeck.


There are many parts of Rural Texas that are underserved, but complaining about 25 miles one way is not underserved. Half a tank of gas? Most people's cars get at least 20 mpg now, so at $3 per gallon we are talking about nine dollars. Cut out a meal at Mcdonald's. You aren't underserved.

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