The scramble to save rural health care from DOGE | Can an Alabama health clinic survive the “chainsaw for bureaucracy”?

> Efficiency was not exactly the concern when Waits, a family physician and obstetrician, first started practicing medicine in 2003. He was a doctor’s son who had grown up in Alabama and been raised Southern Baptist, and his most fundamental conviction was that all human beings deserved health care, a belief that almost took him to Indonesia as a medical missionary until that plan got stalled. Instead, he moved to a town called Centreville, the seat of rural Bibb County, on the edge of Alabama’s Black Belt region, a fertile swath of the state defined first by slavery, then by the civil-rights movement, and that was now a lush green landscape of decaying towns, tornado-blasted trailers, chronic illness, and afflictions more common in developing nations.

> After one week of seeing patients, Waits realized that the mission field was Alabama. And six months after opening his first clinic inside a red brick house in Centreville, he realized that policy ideas that had enthralled him as a college student, such as health savings accounts for the uninsured, made no sense for people who had nothing to save. He had patients who skipped appointments because they had no gas money. He had one who tried to pay his bill with pine straw, offering to landscape the flower beds outside the clinic.

> Waits and his practice partner, Dr. Lacy Smith, another Alabama-born family-medicine physician, who joined Cahaba in 2011, had taken a “blood oath” never to turn anyone away, but the regular business model was not working. The two doctors were waiving appointment fees left and right for patients who could not afford them, and every hour came someone who needed not only a doctor but help with food, housing, or transportation, which the doctors would often cover out of their own salaries. So, in 2012, they converted Cahaba into a “federally qualified health center”—commonly known as a community health center, a nonprofit designation that enabled the clinic to receive specific Medicaid and Medicare reimbursements in exchange for doing what it was already doing. The idea went back to President Lyndon B. Johnson’s War on Poverty, a vision of how the government could create a more equitable country. Waits and Smith soon saw what that could mean.

> As their nonprofit expanded, the percentage of low-income people with access to affordable care in Centreville rose from 7 percent in 2010 to 49 percent in 2014, according to federal data. Meanwhile, provisions of the Affordable Care Act were kicking in. The best-known was Medicaid expansion, which Alabama did not accept. A lesser-known provision was THCGME, the result of years of public-policy research and hard-won bipartisan consensus in Washington around solving one of the most persistent problems in American health care: how to get primary-care doctors into rural areas, roughly 80 percent of which the federal government designates as “medically underserved,” and most of which are in Republican states.

> Traditionally, medical-school graduates complete their residencies at teaching hospitals in larger cities, places abounding with specialists, equipment, and nursing support. The idea behind the THCGME program was to establish residencies at health clinics in underserved areas where resources are scarce. The theory was that residents would not only gain confidence practicing medicine in a challenging context but develop a sense of mission about the work, and stay.

> After an elaborate process of getting Cahaba accredited as a teaching health clinic, Waits and Smith welcomed their first group of four residents in 2013. The initial funding allocated $150,000 per resident, enough to pay for their salaries and the support staff needed to retool Cahaba as an educational institution. Smith and Waits were not at all sure the plan would work. But out of the first group of residents, one decided to stay on at the Centreville clinic after she finished. Another one stayed from the second group of four, and out of the third group, all four stayed—a pattern that continued not only at Cahaba but at more than 80 other health clinics that became teaching health centers in other parts of the country. Out of the roughly 2,000 doctors who have graduated from rural residency programs, roughly 70 percent have continued to practice in underserved areas, according to program data.

> As a practical matter, the $175 million federal program was creating a steady pipeline of doctors into some of the nation’s worst health-care deserts: places such as the Choctaw Nation in Oklahoma, inner-city Detroit, and southern West Virginia. And every year, the grant got renewed with bipartisan support, even as Republicans tried to repeal the Affordable Care Act dozens of times.

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