The task of persuading physicians to set up a practice is a daunting one for rural areas across the country.
And the vast acres of California's Central Valley, where town signs boast claims such as "The World's Fruit Basket" and "The Raisin Capital of the World," are no exception.
"Physicians don't want to come to Kaweah in large part because of the payer mix," says Steve Jacobs, physician recruiter for the Kaweah Delta Health Care District. Centered in the city of Visalia, Kaweah Delta serves a population spanning three geographically large agrarian counties.
Here, the population receiving Medicaid (Medi-Cal) is more than one in three. But of dozens of primary care physicians in the region, only 10 are willing to accept it, Jacobs says.
"Reedley, (pop. 22,000) has a beautiful new community clinic, but can't get a physician to come to a rural town. The town of Porterville (population 39,000) has been looking for an orthopedic surgeon for at least two years," he says. "The area surrounding us is very rural, and there's not a lot of infrastructure."
Jacobs said the district finally found a gastroenterologist after a five year search, "but he's 58, and in a few more years he'll retire and we'll have to start looking again. We tend to find physicians who are later on in their career. But the job of looking for any specialist for the area can take up to three years."
Kaweah Delta's challenge was clearly documented this week by a federal report entitled "Hard times in the Heartland," which noted that while urban areas across the country have, on average, 72 physicians per 100,000 population, rural areas have 55 and small rural areas have only 36.
"Rural areas continue to suffer from a lack of diverse providers for their communities' healthcare needs," the report said. There are half as many specialists in rural areas compared with urban ones, and a third as many psychiatrists. The situation is only going to get worse, because rural areas have a higher percentage than urban areas of physicians nearing retirement. "Recruitment and retention continue to be a challenge."
According to a multitude of studies, the lack of rural physicians translates into a lack of healthcare, and that means more disease and premature death in rural areas compared with urban parts of the nation.
The shortage of physicians is largely blamed on the fact that one in five of the nation's uninsured, or 8.5 million people, live in rural areas, which have a larger number of residents classified as unemployed and poor than urban areas. Those who lack health insurance or have large deductibles are more likely to avoid or defer care, as the report, issued by the U.S. Department of Health and Human Services, noted.
And if the number of patients willing to seek care isn't enough, the doctors just can't afford to come.
For these residents, many of whom have worked their entire lives in small businesses or for themselves, their only guarantee of healthcare comes only after they turn 65.