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Some of those who pitched Proposition 12 as a cure for rural health care woes now seem surprised that doctors aren’t surging into the countryside. tors via mail-in ballot every three years. Besides insurance, the trust provides defense attorneys to doctors who are sued, and pays doctors’ expenses when the investigators of the Medical Board fine them. The trust is not regulated by the Texas Department of Insurance. As former Insurance Department Associate Commissioner Birnie Birnbaum noted, the trust can charge what it chooses, while regulated companies must charge the rates they file with the department. \(The trust isn’t Texas’ only unregulated malpractice insurer; “risk retention” insurers are also free of state oversight. There’s no federal regulation of Since 2003, the trust has reduced its insurance premiums: 12 percent in 2004; 5 percent in 2005; 5 percent in 2006; 7.5 percent this year; and 6.5 percent for 2008. In 2008, the trust will charge doctors 68.7 percent of the charge before tort reform. Dr. Donald A. Behr, head of TMA’s rural physician group, speaks enthusiastically about his rural practice in Graham, seat of Young County in North Central Texas. Behr and his wife, a nurse, left Fort Worth six years ago and say they love treating the smaller community of neighbors and friends, “not just insurance cards.” Graham’s hospital is better off than most rural facilities, said Behr, a general surgeon. An old oil town, Graham was flush with millionaires 25 years ago; their philanthropy keeps the hospital afloat. Of the five counties bordering Young, only one has an obstetrician. Graham has one, but no neurosurgeon, orthopedic surgeon, or cardiologist. Specialists ride in weekly or monthly, like pioneer circuit riders, from Wichita Falls, Mineral Wells, and Abilene. Graham Regional Medical Center draws from Jack, Stevens, Throckmorton, and Archer counties. “Part of that is because of our obstetrician, part probably because of me:’ Behr said. A frantic edge comes to Behr’s otherwise confident voice when he describes the hospital’s financial fragility despite philanthropy. “Most of the obstetrics patients in rural Texas are Medicaid;’ which pays rural physicians less than urban ones, he said. Just to offer obstetrics, Graham’s hospital has to jump through a few hoops. First, the hospital has to have a minimum of two doctors who deliver babies and accept Medicaid, Behr said. Fortunately, Graham has three family practice physicians who also provide obstetrics to back up its lone obstetrician. “A little hospital with one doctor doesn’t fly;’ Behr said. “You’ve got to have anesthesia, and if you don’t have enough volume for a full-time anesthetist, you can’t have obstetrics, basically?’ Graham’s hardworking obstetrician sees patients six days a week, traveling to five towns, and his nurse-practitioner sees the women at other times. In an interview, Behr scarcely mentions liability insurance as a factor facing rural health care. Adequate reimbursementgetting paidby Medicare, Medicaid, and private insurers to cover costs topped Behr’s concerns, expressed in a long conversation. “The only way to keep doctors in rural Texas and anyplace is, somehow we have to find a way to practice medicine cheaper;’ he said. “We spend too much, yet there’s a lot of doctors who can’t make a living?’ Tort reform may have failed to brighten health care for rural Texans, but two state agencies are trying to lure physicians and other health care professionals to underserved areas. The seven-year-old Office of Rural Community Affairs gives doctors stipends of up to $15,000 a year for residency practice after medical school in underserved areas. A separate program in the state office uses $112,500 a year in interest from the state’s share of the massive tobacco lawsuit settlement to recruit and retain licensed nonphysicians, such as nurses and physical therapists, in underserved areas. Another $2 million in tobacco money is distributed by the office to small rural hospitals. The 2007 Legislature increased funding for a doctor education-loan repayment program administered by the Texas Higher Education Coordinating Board. For the current biennium, the program will hand doctors $1 million annually. Loan program Director Lesa Moller said doctors willing to practice in underserved areas can receive up to $9,000 for each year they complete. After two years, the doctor becomes eligible for federal matching funds of up to $18,000. “Unfortunately, there’s been way more applicants than there’s been dollars:’ said TMA lobbyist Helen Kent Davis of the assistance programs, adding that the TMA has advocated for the rural programs at the Legislature for many years. TMA does not fund any rural doctor programs, Davis said. The irony that tobacco-settlement money is put to work year after year sustaining rural health care professionals and hospitals should not be lost on Texas physicians who campaigned for Proposition 12. The massive tobacco settlement was the work of trial lawyers, the very folks TMA leaders demonized in their quest for cheaper insurance and fewer lawsuits. Suzanne Batchelor is a freelance writer in Austin. OCTOBER 19, 2007 THE TEXAS OBSERVER 13