Two decades ago, as a brand new professor, I worked with a team of researchers studying access to healthcare in rural West Virginia. Our goal was to identify ways to measure the effects of not receiving medical treatment or the barriers that might prevent patients from following healthcare. This research was performed at the Robert C. Byrd Center for Rural Health.
As most readers will imagine, it is difficult to isolate the effects of access to medical care on patients. People who don’t have health insurance or seek regular medical care also tend to have other problems that make poor health worse. Thus, the statistical tools used by economists probably cannot differentiate between a patient’s inability to access care and another underlying condition linked to poverty. It can be as simple as having access to reliable transportation or being able to take an entire day off for a medical exam.
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Medical researchers were no better off. A randomized controlled trial may be ideal for testing a new treatment, but it is not appropriate for something like access to health care. To refuse medical treatment in order to assess the impact on patients is, in such cases, a profound ethical violation.
Yet we researchers needed to measure the effects of access in order to determine whether it was beneficial or unnecessary to send additional funds for health care to these rural areas. The hospital had limited resources and it had to apply them where it would bring the most benefit. The director of the center only cared that we do our best to measure the benefits and costs. He didn’t care where the money was going, only that it offered the most benefits. He was a first-rate researcher and clinician from whom I learned a lot.
Our research team decided to look for natural experiences in patient health records. We were looking for conditions that interrupted normal health care. In a mountainous and rural area, I thought transportation issues were most likely, as bridges and roads were often closed. We also researched the closure of clinics or providers statewide. Neither was successful, but we found an unusual event. The only mammography equipment, which was in a remote rural clinic, broke and lay inoperable for a year. The effects of this incident have become the subject of our study.
We extracted every record of every woman who had visited the clinic in the years before the breakup, and everyone who had been there for three years afterwards. In the years before the machine broke, the use of the machine was constant and the cancer detection rate was almost constant. This diagnostic tool was doing its job.
Once the machine failed, the testing rate for these women dropped to almost zero. The rate has not fallen to absolute zero; some women visited other establishments, the closest requiring a three-hour round trip. However, it can be assumed that the year the machine was inaccessible, there were undetected cancers among this population.
After the machine was repaired, the number of women who had mammograms at the clinic doubled over the next year. These are women who sought treatment near their homes rather than making the long trip to the nearest machine. Unfortunately, the number of cancers detected more than doubled in the months after the machine was put back into service. This means that many women who have postponed a diagnosis of breast cancer have missed a chance to catch their tumor at an early stage, when the disease is more survivable.
This was an incident at a small clinic, but it demonstrated that the absence of this machine locally turned out to be a huge barrier to screening. COVID has caused these kinds of disruptions across the country. It’s been 20 years, and honestly, I can’t remember all of the political results of this study except that a mobile mammography trailer was purchased and used in parts of rural Appalachia. I had largely forgotten about this study until last spring when my wife was diagnosed with breast cancer. Like many women, her cancer was found during routine annual screening.
In many ways my wife has been lucky – if luck is the right way to describe any cancer diagnosis. His annual screening was only delayed for a few months due to COVID. She was able to reschedule her missed appointment and the tumor did not have time to grow or spread. If she had delayed screening for a year or more, her good prognosis could have been very different. For many Americans, COVID has had effects similar to the broken mammography machine, although the delays were by choice due to concerns about COVID exposure.
My wife is in very good health and is a thoughtful and educated consumer of medical care. She was diligent in postponing her physical exam. Closures of doctors’ offices and full hospitals played only a modest role in the detection and treatment of her cancer. This will not be the case for everyone. As we think about the long-term effects of COVID, we need to consider how many people have delayed medical care due to illness.
Closed doctor’s offices and overwhelmed hospitals will have caused many people to delay diagnosis or treatment. For some, the delay will lead to more difficult treatment or earlier death. For others, it will be an inconvenience that will reduce their quality of life. The United States is a big country, so these delays affect tens of millions of Americans. The delay in simple diagnostic or treatment services will be devastating for thousands of these people, but for the lucky ones it will be just boring. It will all be part of our long struggle against COVID and will have profound and lasting effects, both personally and economically.
October is Breast Cancer Awareness Month. Many local groups, especially our schools, organize events designed to raise funds and encourage women to schedule their annual screenings. It’s arguably the most important breast cancer awareness month, after 18 months when tens of millions of American women missed their annual screening. So now would be a good time to encourage your friends and family, or really anyone you know, to have that checkup they missed during the COVID peak.
Michael J. Hicks, PhD, is director of the Center for Business and Economic Research and George and Frances Ball Distinguished Professor of Economics at Miller College of Business at Ball State University.