There are more pediatricians and family practitioners in the United States than ever, but 15 million American children have almost no access to a physician trained in child health.  Those children live in areas where there is only one pediatrician or FP for every 4400 children.  A study published in Pediatrics shows that many children live where few doctors want to practice.  "Nearly 15 million children (20% of the US child population) lived in local markets with 710 children per child physician, whereas another 15 million lived in areas with 4400 children per child physician.  Almost 1 million children lived in areas with no local child physician.  Nearly all 50 states had evidence of similar extremes of physician maldistribution."

This has been the case since at least the mid-1990s, when Chang and Halfon wrote: "Pediatricians tend to concentrate in states with high per capita income and in states with a larger number of residency training positions.  The failure of market forces to improve the geographic distribution may require manpower policy changes designed to improve distribution in underrepresented states."

Possible solutions include programs such as the national health service corps that ties medical school loans to service in underserved areas.  Some places have developed sophisticated telemedicine programs to provide tertiary care expertise to underserved rural areas.

Such programs work only if tertiary care centers take responsibility for providing primary care in their assigned region.  It is, ultimately, an issue of organizational ethics and mission.  We know it makes a difference.  An article in the Archives of Surgery shows that children with appendicitis do better if they live in an area with more pediatricians.