By Ron French/Bridge Magazine
Kristin and Warren Scaife fishtailed along the gravel road that winds south out of Grand Marais, on the rocky shores of Lake Superior. Kristin was in labor, but she couldn’t go to the closest hospital. Helen Newberry Joy Hospital didn’t have a birthing unit. A decade earlier, Kristin’s mother-in-law had found that out when she rushed to Newberry for a delivery of her own, only to be told she should keep driving. The baby wouldn’t wait, and she gave birth at Newberry without an obstetrician.
Kristin couldn’t drive to the second-nearest hospital either; Munising Memorial Hospital hadn’t had a maternity ward for more than 20 years.
So the Scaifes’ Chevy Prizm tore down the gravel Adams Trail on the first leg of a nerve-wracking two-hour trip to the nearest medical facility with an obstetrics department, Marquette General Hospital.
“We made it in time,” recalls Scaife, 29, an elementary school teacher in Grand Marais who is expecting another baby in August. “In today’s world, where everything is at your fingertips, to be so far removed (from medical care) is a shock.”
You can have a baby anyplace, but if you want an obstetrician in the room, you’d better live in the bottom half of Michigan or near a city. Large swaths of the northeast Lower Peninsula and the eastern Upper Peninsula lack easy access to a hospital with a maternity ward. More than a quarter of Michigan counties don’t have a single practicing OB/GYN physician.
And it’s likely to get worse. Losing money on most births, small hospitals are mothballing maternity wards, while rural communities struggle to attract and keep doctors who typically can make more money in urban areas.
Michigan’s no-delivery zone is a glaring example of medical service shortages across the state – shortages that some hope will be addressed by the growth in medical schools in the state.
Michigan has checkerboard of access
Scaife grew up in Oakland County, which is home to 396 OB/GYNs, the most in the state, according to data from the U.S. Department of Human and Health Services.
“My mother’s a nurse,” Scaife says. “She’s not crazy about (the distance her daughter must travel for obstetric care).”
It’s not just expectant mothers who have trouble finding care. The geographic disparity of medical services in Michigan is sobering. Consider:
* More than 1.8 million Michigan residents live in areas that are considered underserved by primary care physicians, according to the U.S. Health Resources and Services Administration.
* The state needs an additional 192 primary care doctors in underserved areas, 10th highest in the nation.
* There are no Level 1 trauma centers in the northern half of Michigan, and no Level 1 pediatric trauma centers north of Grand Rapids, according to the American College of Surgeons. Level 1 trauma centers provide the highest level of surgical care.
* There are 22 counties without a practicing OB/GYN. By comparison, every county has a veterinarian.
* There are 30 counties without hospital-based obstetric services, ranging from Cass County on the Indiana border to Ontonagon County at the western edge of the Upper Peninsula.
Washtenaw County has more OB/GYNs (130) than 62 Michigan counties combined. There’s one OB/GYN for every 2,653 residents in Washtenaw County, the highest rate in the state, one for every 22 pregnant women, based on the number of live births in the county.
By contrast, there is one practicing OB/GYN in Allegan County to serve a population of 111,000, a rate 40 times higher. (Allegan residents do have access to OB/GYNs and hospital obstetric units across the county borders to the north and south.)
Population is a factor, but it doesn’t completely explain the state’s no-delivery zones. For example, there are four OB/GYNs in Alpena County, with a population of 29,500, but none in Roscommon County, population 24,500.
Demographics drive doc distribution
The no-delivery zones are a result both of medical economics and a rapidly aging population in Northern Michigan. In the 21 counties in the northern third of the Lower Peninsula (going north from Manistee County on the west and Iosco County on the east), the population is shrinking and aging. One in five residents is over the age of 65, compared to one in seven in the state as a whole. In the 2010 Census, only 15 percent of the residents in those rural northern Michigan counties are women of childbearing age (15-45).
Fewer pregnancies means less work for OB/GYNs, explains Kathy Garthe, vice president of regional system development at Munson Medical Center in Traverse City.
“There are about 5,000 deliveries across 21 counties and about 2,000 are in the Traverse City area,” Garthe says. “For example, one hospital averages 183 deliveries per year. Since (obstetrics work) happens 24/7, you tend to need to have three or four doctors to handle all the calls. Can you have three or four doctors with an OB practice in an area with so few births?”
Meanwhile, hospitals lose money on births covered by Medicaid, which pays for more than half the births in Michigan, according to the Michigan Health and Hospital Association.
“Medicaid pays less than it costs to staff and operate a labor and delivery service,” William Russell, CEO of Three Rivers Health, said in testimony before the House Appropriations Subcommittee on the Community Health Budget in March. “In Three Rivers, 70 percent of our labor and delivery services are to Medicaid patients. A delivery costs roughly $5,000, and Medicaid pays us just under $3,000 for mother and child.
“When you lose significant dollars on every delivery, it is only a matter of time before that service must be eliminated.”
In the 1980s, there were more than 220 Michigan hospitals, virtually all independent. Now there are only 137, with 87 offering obstetrics units, according to the Lansing-based Michigan Health and Hospital Association. Six Michigan hospitals have closed obstetrics units in the past three years, with four of them in Mid- or Northern Michigan: West Branch, Cheboygan, Shelby and Clare.
“It’s not a shortage of services, it’s mal-distribution,” said Donna Jaksic, executive director of the U.P. Association of Rural Health Centers. “Services are not always as easily accessible because of cost or perceived cost.”
Rural communities have trouble attracting doctors, who often emerge from medical school with more than $100,000 in student debt and congregate in metropolitan hospitals offering higher wages.
“The market is in their favor,” Jaksic says. “Sometimes we offer (a prospective physician) a good package, and they can make twice as much in the south. Sometimes it’s a challenge of an occupation of their spouse. We’ve interviewed physicians whose spouse was an aeronautical engineer.”
CMU looks to fill a gap
The physician shortage in Northern Michigan is one of the reasons Central Michigan University is opening a medical school in the fall of 2013. “We have a shortage of physicians in Michigan and that shortage contributes to problems accessing health care in rural areas,” said Ernie Yoder, dean of the CMU College of Medicine. “The shortage is more severe north of Mt. Pleasant.”
Yoder believes the greatest shortage up north is psychiatric services, followed by general surgery, OB/GYN and primary care. Jaksic adds dermatology and orthopedics. “We have people traveling hundreds of miles to get to a dentist who accepts Medicaid,” Jaksic said.
Because of geographic disparities in medical care, rural Michiganians pay a premium for seeing a doctor — a premium paid in time, gasoline and wear-and-tear on their vehicles.
It’s not surprising to hear Scaife say she doesn’t make the two-hour trip to Marquette each month for a pre-natal visit. “It’s such a long drive,” she says. “I wish there were something else available. But we live where we are because we have jobs.
“Luckily not a lot of people here have babies,” Scaife says with a laugh. “To be pregnant and have a child in this town is a pretty big thing.”
Senior Writer Ron French joined Bridge in 2011 after having won more than 40 national and state journalism awards since he joined the Detroit News in 1995. French has a long track record of uncovering emerging issues and changing the public policy debate through his work. In 2006, he foretold the coming crisis in the auto industry in a special report detailing how worker health-care costs threatened to bankrupt General Motors.