As the federal government enters its third week of shutdown, lawmakers remain deadlocked over whether to extend enhanced health insurance subsidies for Affordable Care Act Marketplace plans. Without congressional action, the subsidies, which were first expanded in 2021, will expire at the end of the year, increasing out-of-pocket costs for over 20 million Americans. For many, the fight feels like another chapter in the country’s long struggle to balance access to care with cost and quality – and indeed, this tension isn’t new. It can be traced back more than a century, to a man named Abraham Flexner, whose 1910 report transformed modern American medicine and, in doing so, redefined who could access it . When the Flexner Report was released in 1910, it became the catalyst for a complete reshaping of the American healthcare system. Abraham Flexner argued that U.S. medical education lacked modernization and scientific rigor, and his report sought to transform the field by establishing stricter standards for university curriculum and entrance requirements. With $50 million from the Rockefellers to implement his recommendations, Flexner’s preferred institutions flourished, while those he deemed “substandard” struggled to survive. Many states followed his lead, issuing lists of schools whose diplomas would no longer be recognized, making it difficult for them to attract potential students. While his efforts successfully raised the standards of medical education, they also resulted in a system that centralized medical education to elite, urban universities and shuttered dozens of smaller programs that had primarily served rural and Black communities. Flexner’s report centered around the belief that medical practice should be entirely rooted in the natural sciences, particularly chemistry and biology. He criticized the low entry standards in many medical schools – albeit a fair critique, given that some schools didn’t yet require a high school diploma – and demanded that admission require at least two years of college-level science. He also insisted that medical schools operate as full-time, research-driven university departments. These proposals faced resistance for harboring “animus for smaller institutions,” and indeed, his reforms contributed to a decline in the number of medical schools from 160 to 76 between 1910 and 1930, most of which were small and rural. Flexner founded his reforms on the belief that rural “family doctors” without standardized scientific training were, at best, ineffective and, at worst, lethal, insisting that “it is better to have no doctor at all than a badly trained one.” While his reforms improved the quality of medical care nationally, they also dramatically reduced access, particularly for rural and historically underserved communities. Although Flexner’s efforts were well-intentioned, they disproportionately closed schools that had been the only ones accessible to poor and geographically isolated students. The graduates of these institutions, while perhaps below Flexner’s standards of scientific excellence, completely made up the staff of the few-and-far-between health clinics in rural America. By prioritizing scientific accuracy over access and declaring the “family doctor” obsolete, Flexner’s reforms left vast regions of the country without physicians – a void that compounded as states withdrew recognition from schools he disapproved of. In pursuit of a more modern healthcare system, Flexner inadvertently stripped rural America of much of its medical workforce. Flexner’s report also had significant racial repercussions. In a chapter titled “The Medical Education of the Negro,” he claimed that five of the seven predominantly Black medical schools in America were “in no position to make any contribution of value.” He recommended that only Howard and Meharry remain open, with the specific purpose of training students to “serve their people humbly” as “sanitarians.” By 1925, his recommendations were fully realized: five Black medical schools closed, and the two survivors were effectively relegated to producing non-surgical, non-research practitioners due to the stigma imposed on Black physicians by Flexner’s report. A 2005 National Medical Association panel investigating the historical roots of racial discrimination in organized medicine prompted a formal apology from the American Medical Association for “its past history of racial inequality towards African American physicians.” In this, the AMA recognized that Flexner’s recommendations not only marginalized Black physicians but also deprived Black communities of access to care – as the schools that closed had primarily served Black patients. By midcentury, the physician shortage Flexner had encouraged became a public policy crisis. A 1988 congressional report found that only 18.6% of doctors practiced in rural areas, and despite “health manpower” legislation in the 1960s, the gap persisted. A RAND study claimed more board-certified physicians were moving to rural communities, but the retirement of the “general practitioners” Flexner’s report had rendered extinct kept access to care stagnant. In reality, counties with fewer than 10,000 residents had only one-third of the national average of physician availability. The legacy of that shortage remains visible in what researchers call the “southern rural health penalty”: rural southern counties, especially those with large Black populations, still experience the nation’s highest poverty and mortality rates. The same regions where Flexner once deemed medical care insufficient and unscientific now suffer the worst health outcomes in the country. Flexner believed that consolidating medical schools would standardize care – but in practice, it all but eliminated rural medical education, leaving the 60 million Americans living in rural areas with little to no access to health care. There was no care left to standardize. Recent efforts have shown greater success in rebuilding a base of physicians and medical schools in rural America. Rural Training Track (RTT) programs, now established in several states, aim to train medical residents directly within rural communities and prepare them for long-term rural practice. Their “1-2 model” trains residents in an urban hospital for one year, followed by two years in a rural clinical setting – a program that has proven effective, with 27 of the 35 RTT graduates having continued to practice in rural areas as of 2010. New legislation, including the Consolidated Appropriations Act of 2021, has further expanded funding for RTT programs and removed bureaucratic barriers that once prevented urban medical schools from sponsoring rural training tracks. However, the lasting damage of Flexner’s report is not easily undone. A 2023 study projected that rural America will face a 56% physician shortage in 2036, compared to just 6% in metropolitan areas. More than a century after Flexner declared that poorly trained doctors should be eliminated, much of rural America has simply gone without any medical access at all. Flexner’s revolution transformed medicine into a precise science, centralized expertise, and elevated national standards for care – but completely hollowed out the reach of the medical industry. These reforms entrenched inequality of care in rural America, and left behind the communities that could least afford to lose their available doctors. Today, as lawmakers once again debate how to make health care more affordable and accessible, they’re still grappling with the same divide Flexner set in motion.
