III. A Call for Action

A. The ACA Provides the Framework

The ACA provides a framework for recruiting physicians, especially primary care physicians, and training them in the area of cultural *77 competency. With the enactment of the ACA, our administration recognized many of the issues addressed in Part II. Our health care system is fractured. The system of managed care does not encourage relationship-building between physicians and health care providers in general, and especially between physicians and their rural elderly African American patients.

The provisions of the ACA discussed in Part III may assist with recruiting and training a workforce that is able to address the needs of the rural elderly African American population. However, questions certainly remain. To begin with, are the incentives outlined in the ACA enough of an incentive for a younger generation of physicians to move into primary practice in general, and specifically into a rural area? Pipeline programs must be put in place to recruit and train those who are likely to serve the rural elderly populations.

Data suggest that children who grow up in rural areas are more likely to practice in those areas.  Also, “[m]inority physicians are more likely to practice in some of the communities hardest hit by the health disparities.”  Unfortunately, these individuals are not attending medical school in large numbers. Medical schools are homogenous, with very little economic or ethnic diversity. As of 2008, 7.1-7.3% of entering medical students identified as African American, 7.4-7.5% as Hispanic, 20-21% as Asian, and 62-63% as Caucasian, non-Hispanic.  An increasing percentage-- 55%, up from 51%--of new medical students have come from the top quintile of family income, while the percentage of new medical students who come from families in the lowest quintile has remained below 5.5%.  This homogeneity has created a health care system that is unable to properly care for the increasing number of patients who are not part of the system's dominant culture.  It affects “(1) the manner in which patients understand and seek health care; (2) the attitudes of health care providers; (3) the way providers approach offering health *78 care services; and (4) the organizational system.”  Although health care providers may determine what health care their patients need, they do not always give the same care to all patients.

B. Diversity in Medical School Is Necessary

If we wait until students reach medical school to address issues of cultural competency and practicing in remote areas, we have waited too long. To attempt to teach cultural competency to a homogenous group of medical students may be a fruitless endeavor. When medical schools are homogeneous, both ethnically and economically, the training and incentives that the ACA offers may be useless.

Effective cultural competency training requires a diverse population of students. Effective training requires an audience with various racial, cultural, economic and religious backgrounds. The interaction with such diverse individuals is the smartest way to eliminate assumptions, biases, and stereotypes that may impede a physician's ability to make sound medical recommendations or diminish the patient's trust in the physician. “[T]he benefits of classroom diversity in medical schools extend far beyond the classroom. Ideally, the physician workforce will mirror the increasingly diverse society in which it practices.”  To accomplish this, we must develop “a pipeline of . . . youth interested in both health care careers and returning to or remaining in rural communities.”