The State of Surgical Care Access in America: Current Challenges,Disparities,and Emerging Solutions

Abstract

Access to surgical care represents a significant and widespread issue that impacts millions of Americans across varying demographics. It is estimated that nearly 100 million Americans—approximately 1 in 3—lack access to quality surgical care. Additionally, the financial implications of this lack of access lead to an estimated annual cost of $1 billion in preventable healthcare spending, coupled with increased morbidity and mortality rates. Reliable access to care includes sufficient and affordable health insurance and the ability to easily locate and receive care that meets the patient’s health needs. The barriers to timely, affordable, quality surgical care are complex and multifaceted. They include population-based factors such as rural geography, the repercussions of hospital closures, access challenges faced by justice-involved individuals, LGBTQ+ patients, and other marginalized groups, language and cultural barriers as well as the impact of natural disasters on supply and health system infrastructure, bias and discrimination, and policy.

Access to surgical care represents a significant and widespread issue that impacts millions of Americans across varying demographics. It is estimated that nearly 100 million Americans—approximately 1 in 3—lack access to quality surgical care. ¹ Additionally, the financial implications of this lack of access lead to an estimated annual cost of $1 billion in preventable health care spending, coupled with increased morbidity and mortality rates. ² Reliable access to care includes sufficient and affordable health insurance and the ability to easily locate and receive care that meets the patient’s health needs. ³ The barriers to timely, affordable, quality surgical care are complex and multifaceted. They include population-based factors such as rural geography, the repercussions of hospital closures, access challenges faced by justice-involved individuals, LGBTQ+ patients, and other marginalized groups, language and cultural barriers as well as the impact of natural disasters on supply and health system infrastructure, bias and discrimination, and policy.

Limitations in medical education hinder the availability of a qualified surgical workforce, especially in light of anticipated significant surgical shortages in the near future, which will tremendously impact access to surgical care. Surgical training is still associated with high attrition rates, as high as 17% in 2021, creating fewer surgeons entering the workforce. ⁴ It is important to note that attrition rates are higher among women and underrepresented minorities, both of which have increased in number within surgical training. ⁴ Additionally, these populations are underrepresented in academic surgery faculty positions, leadership roles within surgical departments, and major surgical organizations. This lack of diversity may contribute to a decline in the number of medical students who choose the surgical field, thereby reducing our workforce. Furthermore, these populations often address issues related to access to care. ⁵

Hospital closures have occurred with increasing frequency, impacting and decreasing access to surgical care. Closures in urban and rural settings have led to more extended travel and appointment wait times. In addition, these areas may be undesirable work locations for some physicians, leaving the communities with decreased resources available when surgical care is needed. General surgical care can be more accessible than subspecialized care, which is often only available at tertiary, high-volume centers. ⁶ The closure of Atlanta Medical Center, a level 1 trauma and acute care medical center in Atlanta, in 2022 reverberated impacts on access to care. As the city’s population continues to increase, the loss of medical facilities significantly affects access to care for populations as existing hospital systems are strained to meet the increased demand. ⁷ The closure of Atlanta Medical Center follows more than 9 Georgia rural hospital closures between 2008 and 2020, further reducing access to care, including surgical care, primary care, and obstetrics services, also known as maternity care deserts.^7,8

In response to the increasing shortages of health care providers, the ACGME has established its initiative on Medically Underserved Areas and Populations to tackle the significant population without access to care by improving physician workforce development. ⁹ As a result, they have created a framework to encourage graduate medical education development that will increase access to care in these medically underserved areas. ⁹ Meanwhile, rural surgical training pathways provide necessary exposure for surgical trainees at rural training sites to improve health care in these medically underserved communities. The significant benefits include exposure to rural surgical practice, increased regional and state collaboration, and a potential pipeline of surgeons to impact the dearth of the surgical workforce and improve access to surgical care. Emory University has established a surgical rotation partnership with Colquitt Regional Medical Center, a 99-bed teaching hospital in Moultrie, Georgia, to increase the exposure of surgical residents to the rural surgical environment. ¹⁰ The General Surgery Residency at Augusta University also provides rural surgery rotations within Georgia for their residents to increase exposure to rural communities and practices. Several universities have established rural health initiatives, such as the Mercer University School of Medicine Georgia Rural Health Innovation Center, which addresses health disparities and challenges in rural communities. ¹¹ Additionally, Augusta University has established a Center for Rural Health to improve patient care and outcomes in rural communities. ¹²

The impact of environmental determinants on access to surgical care has been increasing and more impactful. These determinants include extreme weather events such as hurricanes, tornadoes, flooding, and wildfires. The myriad of impacts is significant, including disruption of infrastructure such as roads, loss of access to treatments and medications, supply chain disruption, hospital closures, increased traumatic injuries, increased preterm labor and maternofetal impacts, forced relocation/evacuation, and long-lasting mental health impacts.^13,14 Studies demonstrated an increase in preterm labor and traumatic injuries after Hurricane Sandy struck New York City in 2012.^15-17 The devastating Hurricane Helene and Hurricane Milton in 2024 caused significant infrastructure destruction, hospital closures, and supply chain disruption. The hurricanes impacted Baxter IV fluid supply, causing widespread supply chain challenges, which impacted elective surgeries and dialysis.^14,18

Health care policies and insurance coverage also play a crucial role in determining access to surgical care. Research indicates that a substantial percentage of the US population is uninsured or underinsured, significantly impacting their access to care. ³ In 2016, 28 million Americans younger than 65 were uninsured. ³ Studies have demonstrated that access to care improved following the implementation of the Affordable Care Act, leading to better life expectancy and patient outcomes.^19,20 Unfortunately, several southern states did not elect to participate in expanding Medicaid. These states tend to have poorer health outcomes and access to care and higher health care costs than expansion states. ²¹ Georgia is one of 10 states that has not provided full Medicaid expansion, which would provide government insurance to hundreds of thousands and improve access to care. ²² Additionally, Georgia ranks third in the nation for the highest rate of uninsured persons, partly due to the lack of Medicaid expansion. ²³ A recent review of more than 400 studies that reviewed the impact of the passage of the Affordable Care Act demonstrates that Medicaid expansion in states resulted in significant increases in coverage among low-income and vulnerable populations. Additionally, the studies demonstrate increased access to care, affordability, and positive health outcomes.^19,20 However, in Georgia, through dedicated advocacy by surgeons, and advocates such as Dr Renee Hilton, Dr Danny Vaughn, Kathy Browning, Dr Shaneeta Johnson, and the Georgia Chapter of the American Society of Metabolic and Bariatric Surgery, access to obesity treatment was achieved for state employees as well as a recognition of Obesity Day in the state, significantly increasing access to care for this patient population. ²⁴

This symposium on access to care convenes experts in surgical education, clinical practice, advocacy, technology, and health care accessibility to explore the multifactorial reasons behind reduced access to surgical services and to propose actionable strategies to alleviate these challenges. We extend our gratitude to the authors for contributing to this important collection. We hope the readers will enjoy this selection of articles from thought leaders in surgery and that these articles will positively impact your practice and community.