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The Distribution of America's Medical Schools THE DISTRIBUTION OF AMERICA’S MEDICAL SCHOOLS AND THE PERSISTENT PROBLEM OF PHYSICIAN ACCESS ____________ A Thesis Presented to the Faculty of California State University, Chico ____________ In Partial Fulfillment of the Requirements for the Degree Master of Arts in Political Science ____________ by © Ginger M. Alonso Spring 2018 PUBLICATION RIGHTS No portion of this thesis may be reprinted or reproduced in any manner unacceptable to the usual copyright restrictions without the written permission of the author. iii DEDICATION For Ben, Chloe, and Bethany. I believe in you. iv ACKNOWLEDGEMENTS I wish to acknowledge My family for their patience and understanding as I became absorbed in this project. Ms. Susanna Boxall for welcoming me to her fascinating Health Ethics class at Chico State; having that experience certainly helped me write my first chapter. Ms. Katy Sylvia for giving me such a great introduction to the department that I was able to connect and grow through the program after years out of academia. Dr. Alan Gibson for being confident in me from day one in the master’s program. His generous investment of time, energy, and expertise has helped me complete this research and has given me assurance for future academic adventures. Ms. Pam Nelson for her inspiring hands-on dedication to physicians, community, and the democratic process. Dr. Becky White for her support, advice and feedback, and most of all for being my role model - like me in some ways, and yet simultaneously epitomizing everything I strive to be. Dr. Matt Thomas for understanding my approach to research not only in the academic context, but in the context of a life’s work. His contributions to this thesis were many, but it is Dr. Thomas’ example of living a life rooted in the local academic community while actively growing as an individual scholar that left the greatest impression on me. Dr. Diana Dwyre for her kindness and unwavering dedication to excellence demonstrated by the quality time and attention she always gave to me and my multiple drafts. v Dr. Andy Potter for being that enthusiastic thesis chair who students inevitably recommend to their peers. His support through the writing process - from chaotic abstract ideas to organized chapters - draft after draft, kept me focused and paced. Dr. Potter shared knowledge that was always several steps ahead, and last but certainly not least, motivated me to do my best. vi TABLE OF CONTENTS PAGE Publication Rights ............................................................................................................. iii Dedication ......................................................................................................................... iv Acknowledgements ........................................................................................................... v List of Tables .................................................................................................................... ix List of Figures ................................................................................................................... x Abstract ............................................................................................................................. xi CHAPTER I. Introduction to the Study ...................................................................................... 1 Theoretical Background ............................................................................... 1 The Enduring Significance of Medical School Location ............................. 2 The Essential Physician ............................................................................... 3 In-State Competition and Unequal Access .................................................. 5 Theoretical Framework ................................................................................ 7 Libertarian Approach: Health Care as a Service.......................................... 8 Utilitarian Approach: Maximizing Happiness Over Burden ....................... 11 Egalitarian Approach: Healthcare as a Positive Right ................................. 13 “Fair Equality of Opportunity”: Norman Daniels ........................................ 16 Conclusion ................................................................................................... 21 II. Historical Background .......................................................................................... 23 Introduction .................................................................................................. 23 Early Stages of Medical Education .............................................................. 23 Industrialization and Urbanization ............................................................... 30 Medical School Reputation and University Affiliation ............................... 33 John Hopkins Model .................................................................................... 37 Flexner Report ............................................................................................. 39 1920s to Today ............................................................................................. 45 The Physician Shortage and Medical Schools in the United States Today ........................................................................................... 53 vii CHAPTER PAGE III. Data and Methodology .......................................................................................... 59 Introduction .................................................................................................. 59 Research Approach ...................................................................................... 59 Data and Methodology ................................................................................. 60 IV. Results and Discussion ......................................................................................... 63 Hypothesis.................................................................................................... 63 Discussion .................................................................................................... 66 Conclusion ................................................................................................... 68 V. Conclusion and Recommendations for Future Research ...................................... 69 Aims of Research ......................................................................................... 69 Summary of Findings ................................................................................... 69 Theoretical Implications .............................................................................. 79 The Dual Health Care System in a Theoretical Context .............................. 71 New Medical Schools - A Misguided Solution?.......................................... 73 The Role of Graduate Medical Education ................................................... 77 PCPs, GME, Medical Schools and Institutional Priorities .......................... 78 Limitations ................................................................................................... 80 Recommendations for Future Research ....................................................... 81 Conclusion ................................................................................................... 82 Bibliography ..................................................................................................................... 84 viii LIST OF TABLES TABLE PAGE 1. U.S. Medical School Growth, 1960-1961 to 2008-2009 ............................... 52 2. Predictors of Physician Access (Physicians Per Capita) in States ................. 65 ix LIST OF FIGURES FIGURE PAGE 1. Medical Schools: The United States ............................................................... 2 2. Number of Medical Schools and Physician Access Per Capita ...................... 64 x ABSTRACT THE DISTRIBUTION OF AMERICA’S MEDICAL SCHOOLS AND THE PERSISTENT PROBLEM OF PHYSICIAN ACCESS by © Ginger M. Alonso Master of Arts in Political Science California State University, Chico Spring 2018 This thesis is a study of the relationship between the number of medical schools in a state and physician access, and the implications of this for rural and poor Americans. Access to care is a growing concern in the United States today. Research confirms that health status indicators including rates of life expectancy, timely treatment, and preventative care all increase with physician access. Access disparities have led the federal government to provide funding and incentives for physicians practicing in regions known as designated Health Professional Shortage Areas (HPSAs). One possible explanation for the persistence of this problem is that medical schools have been historically located in urban centers on the East Coast in geographically smaller states. By examining the relationship of the number of medical schools in each state to the ratio of physicians to population in each state, I hope to shed light on the phenomenon of the rural physician shortage, including the sources of this problem and how it might be addressed. Research on this topic is particularly relevant today xi because the “Silver Tsunami” brought about by the aging of the American population promises to significantly increase demands for health care in the United States. Increasing demands will be difficult to meet through the existing rate of expansion of the physician workforce. In this context, physician access and state medical schools
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