Iowa's physician shortage

 

Zach Kucharski of the Gazette introduces the panel

Iowa is last in the nation in obstetricians per capita, which is felt most acutely in rural areas where fewer hospitals are offering obstetrics or even pediatric services. Iowa is also third-lowest in the US in retention of physicians. Those are only two data points in an overall shortage of physicians in the Hawkeye State, which was the subject of the latest Gazette Business Breakfast earlier this week. 

Two days later, Iowa earned the infamous distinction of being the first state in the U.S. to shrink its civil rights ordinance by removing gender identity from protection. The action was justified by the legislature's earlier attempts at punishing transgendered people being struck down by the courts as running afoul of this ordinance. Without the pesky civil rights ordinance, our government is free to take whatever potshots at transgendered people that it feels like taking. What an expression of our state's official hostility to difference!

At first glance, these are two different topics. Is it possible, though, that they are connected?

Unity Point Medical District, where your humble blogger gets his doctorin'
(Google Earth screenshot)

At the Gazette event, panelists Dr. Fadi Yacoub (Linn County Medical Society), Dr. Timothy Quinn (Mercy Medical Center), and Dr. Dustin Arnold (Unity Point Health) were interviewed by the Gazette's Zach Kucharski. They referenced two main strategies for improving Iowa's physician retention: improving the doctors' bottom lines, and incentives for Iowa students to do their medical education in Iowa.

Despite Iowa's reputation for low cost of living, Quinn noted physician salaries are not keeping up with increasing levels of medical school debt, and insurance payments relative to cost of living are are comparatively low. Arnold suggested the state should see positive effects of "tort reform," which means the legislature has capped damages for medical malpractice suits. Current legislation (HSB 191) before the Iowa legislature would offer student loan repayment programs for rural doctors, and commission a study of the effects of cutting medical school from four years to three (cf. Murphy and Barton 2025). On the other hand, would-be budget cutters in Washington are looking at Medicaid, which is "essential to medical care in Iowa" (Quinn's phrase) due to the directed payment program.

The legislature is also hoping to improve retention by keeping Iowa residents in the state, creating preferences in medical school admissions. (The University of Iowa, though, is 78 percent Iowan, already near the 80 percent target for schools.) The thought is that people who are close to family and already appreciate the wonders of Iowa will want to stay here. "We don't have pro sports, we don't have concerts, but" Iowa is a state you love, said Yacoub, noting he was "preaching to the choir here." Arnold of Unity Point added Cedar Rapids is a great place to live, "once you're here you want to stay." This may or may not be true, given the state's (not the city's) regressive political culture, but even if we retain 90 percent of Iowa-based doctors the gap between working age doctors and our aging population will continue to increase.

When we take on faith that Iowa is so great you could confuse it with heaven ("Field of Dreams" reference), it precludes serious discussion of our future. When we take on faith that the most important considerations are low taxes, we miss the thousand things that make for quality of life (some of which are paid for with taxes). I'm an urbanist, not a physician, and tend to see things through an urbanist lens. As such I'm probably missing important dimensions of this specific problem. But we want more physicians to move here, we need to think about how to make it an attractive place for everybody.

Iowa's physician shortage exists in a national context. Quinn noted at the start medical schools nationwide have not kept up with demand, so the whole country must rely on immigration to make up the gap. (Yacoub, who came to the United States in 1989, is one example.) Later he noted the shortage of doctors extends to nurses and support staff as well. 

But it also exists amidst a sociopolitical context in our state that is becoming increasingly hostile to difference. As Richard Florida noted two decades ago, it is openness, not turning inward, that welcomes a variety of people with varieties of talents. Iowa, except for a few larger counties, is shedding population like no one's business. We have managed to combine the worst of northern weather and southern politics: Our policies and public statements are openly hostile to poor people, immigrants, the transgendered, and city dwellers, just for starters. What message does that send to anyone else who might be or feel a little different? 

The physician shortage is making working conditions for current physicians worse. As scheduling gets tighter, there is less space in a physician's life for continuing education or even lunch. I wonder how else working in Iowa might affect a physician's desire to be here? No one mentioned COVID at all, but I remember patients stacking up at hospital emergency rooms at the same time (early 2021) Governor Kim Reynolds was declaring the pandemic over. Evidence of the negative health effects of data centers (Criddle and Stacey 2025) and corn sweeteners is accumulating, but they are the darlings of our economic plans. Meanwhile, Iowa has the fastest-growing cancer rate in the country. It can't be easy to practice medicine in an environment that consistently chooses corporate bottom lines over public health, and hostility to vulnerable minorities over building prosperous and inclusive communities.

I can't say with any precision whether Iowa's official penchant for nostalgia and resentment is exacerbating our shortage of physicians. Some early-career physicians may prefer the Politics of Yesterday, while others may be indifferent. But overall it is unlikely to lure the talent we need.

SEE ALSO: "Iowa: You're on the Menu," 9 May 2023