Missouri’s Health Care Disparity Problem

Posted on by Stephen Feman

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.

St. Louis City And County: Divided With Love

Posted on by David Stokes

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.

Beer Cans and Freedom

Posted on by Sarah Brodsky

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.

Saint Louis County Would Benefit From City’s Return

Posted on by David Stokes

In his most recent inaugural address, Mayor Francis Slay stated that it is time for the city of Saint Louis to reenter Saint Louis County, from which it separated in 1876. He’s right — it is time for the people of the Saint Louis region to once again consider repairing this split of 123 years.

First, officials should stop using the term “merger.” Slay’s website uses a much better term: “join.” There is no need for an all-encompassing merger of the city, county, every county municipality, and each fire and library district into one massive leviathan. Plenty of benefits would arise just from the city becoming the county’s 92nd municipality. It would eliminate many government redundancies and reduce the circular-firing-squad tax incentives that area cities engage in.

Conventional wisdom suggests that reentering the county would be an easy sell in the city and a hard one in the county. That assumption is questionable, however, because the primary effect of this change for county residents would be a tax cut. Saint Louis County does not break down its spending by incorporation status, but anyone familiar with county government knows it spends more money per capita on unincorporated areas. Adding 350,000 people to the county, all of whom live within an incorporated area, would vastly expand the county’s tax base without significantly expanding its government responsibilities. Result: A tax reduction for all county businesses and residents.

In 2007, Jackson County — which is dominated by Kansas City and three other large suburbs — spent $389 per person. That same year, Saint Louis County — which has a substantial unincorporated area and many smaller cities — spent $90 more per resident. There is a correlation between per-capita spending and the county’s percentage of incorporation — economies of scale and savings from consolidation of services cannot be ignored.

There are exceptions to every rule, of course. Some small suburbs in Saint Louis County with significant retail activity spend more per capita than Saint Louis city, even though they fall within a county. However, adding the city’s assessed valuation of $4,620,358,944 to the county’s $25,026,505,994, consolidating the benefits of economies of scale in tax collection, assessments, deed recording, etc, and spreading the tax rate among a wider group of taxpayers would result in a lower tax rate for the people of Saint Louis County.

This would obviously entail some expansion of county government responsibility and size, but not anywhere near the amount one might expect from increased population or assessed valuation alone. Every role the county would play within the city would result either from combining operations or replacing the city’s role as the provider of county-level services. There would be no new layer of government authority or duplication of services. Over time, it is likely that the county would take over certain positions within the city, such as maintenance of major arterial roads that serve both the city and county, like Forest Park Parkway, or management of some city parks, in the same way that the county runs Tilles Park in Ladue. These changes would stem from a drive for efficiency, however, not patronage or stimulus, and as a result would save taxpayer dollars, reduce aggregate government spending, and lower the levels of government employment in our area — three worthy goals. The separation of powers works well in the county, and would work just as well when and if the city rejoined the county.

Local governments in Missouri constantly try to use incentives to lure businesses from one city to another. Numerous examples exist of Saint Louis county municipalities using incentives to entice companies to leave the city, and vice versa. If Saint Louis city rejoined the county, however, those pressures would be lessened. And, if the city were required to become a sales tax “pool” city as a condition of reentry, those pressures would be lessened substantially. As a “pool” city, Saint Louis would have far less to gain from retail business incentives, and less to lose as well. There is a reason all of the well-known examples of eminent domain abuse in Saint Louis County have occurred in “point-of-sale” cities like Sunset Hills — those cities have financial incentives to replace homeowners with retail businesses.

The return of Saint Louis city into the county would not adversely affect the people of the county in any more significant a fashion than Florissant affects Ellisville. It would lead to lower property taxes, and reduced pressure for government to hand out development tax incentives. The people of Saint Louis County would be well-served by a return of the prodigal city.

David Stokes is a policy analyst with the Show-Me Institute, a Missouri-based think tank.

 

Switching to Private Utilities Could Fund Springfield’s Pension Shortfall

Posted on by David Stokes

The city of Springfield is currently struggling to deal with a significantly underfunded public pension plan. Officials recently attempted to raise city taxes in order to increase funding levels, but voters defeated that plan. As the citizens of Springfield debate how to fix a problem that isn’t going away, they should consider that their government owns and manages an incredibly valuable asset that the private sector is fully capable of handling: City Utilities (CU).

Springfield is the largest city in Missouri, and one of the larger cities in the country, in which every utility is provided, owned, and operated by the government. CU supplies gas, electricity, water, mass transit, and even some telecommunications services to the people and businesses of Springfield. It’s worth comparing this to how Missouri’s other major cities handle their utilities. In both Saint Louis and Kansas City, private, investor-owned, regulated utilities provide natural gas and electricity. In Saint Louis County, in addition to gas and electricity, the water is also provided by a private utility.

If Springfield were to break up CU and auction its parts to private utilities, it could potentially fund the $200 million pension shortfall and still have a substantial amount of money left over to cut taxes and pay off other public debts, or whatever else the city chooses. It is difficult to estimate the windfall Springfield might receive, because public utility valuations are very complicated, but Webster Groves, which has one tenth the population of Springfield, received $9.5 million in 2002 just for its water system. Using a rough per-capita calculation and adjusting for inflation, a similar sale might bring more than $75 million for Springfield’s water division alone. The city’s gas and electricity divisions would prove similarly valuable.

Last year, after I suggested a similar course of action, a CU representative wrote me a nice letter arguing that the utility was doing a fine job for the people of Springfield. I don’t disagree with that, but he provided as his primary evidence an annual survey of utility companies that generally ranks Springfield among the lowest average winter utility bills in the nation. According to the 2009 survey, winter CU bills averaged $294 — the fourth-lowest ranking. However, Saint Louis, which is primarily served by private utilities, usually falls close behind Springfield in this survey. In 2009, combined winter utility bills in Saint Louis averaged $327, good for an eighth-place ranking. Clearly, private utilities are also providing outstanding service for the people of Saint Louis and Kansas City (the latter of which was not included in the survey). The citizens and leaders of Springfield might well choose to keep CU public because it might save them a few dollars per month, although the logistics of the utility systems in each city aren’t directly comparable. But the tax dollars to fund the pension shortfall have to come from somewhere.

Breaking up CU would be difficult and complicated, no doubt — particularly the disposition of existing bonds — but other utility privatization efforts have overcome similar hurdles. Studies have shown that private utilities are more efficient than public, especially after adjusting for government utilities’ tax advantages, such as issuing tax-exempt bonds and property tax exemptions. Breaking up and auctioning off CU in order to fund the city’s pension shortfall is a short-term solution, but in the long run, the citizens of Springfield would find themselves just as well served by private, regulated utilities. There is simply no reason for every utility service in Springfield to be provided by the government.

David Stokes is a policy analyst with the Show-Me Institute, a Missouri-based think tank.

 

Test Scores and Science Mobiles

Posted on by Sarah Brodsky

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.

Intriguing, Yet Frightening, Comment Over at Political Fix

Posted on by David Stokes

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.

I Can Say This Much for Cash for Clunkers

Posted on by Sarah Brodsky

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.

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