You've probably noticed it without thinking much about it. Drive through a wealthy suburb and you'll pass dentists, pediatricians, urgent care clinics — sometimes three on the same block. Drive through a low-income neighborhood and you might not find a single doctor's office for miles.

This isn't random or accidental. It's the predictable result of how we've designed our healthcare system. The communities where people are sickest and need the most care are often the very places where care is hardest to find. Understanding why this happens — and what's actually being done about it — matters for everyone, because a system that fails its most vulnerable members is a system with cracks that affect us all.

Running a medical practice is expensive. Rent, staff salaries, equipment, malpractice insurance — the overhead is real. And here's the uncomfortable truth: a doctor's office is also a business. It has to bring in enough revenue to cover its costs and keep the doors open.

In wealthier areas, more patients carry private insurance that reimburses well. There's less unpaid debt, fewer missed appointments, and the local infrastructure — pharmacies, labs, specialists nearby — makes practicing medicine smoother and more efficient. The economics simply work better.

In low-income neighborhoods, the math flips. A larger share of patients are uninsured or on public insurance that reimburses less. Patient needs tend to be more complex, meaning longer appointments and more follow-up — without proportionally higher payment. So when a new physician graduates with $200,000 in student debt and decides where to set up practice, the financial calculus almost always points toward affluent communities. It's not that doctors don't care about underserved areas. It's that the system makes it financially risky to practice where need is greatest.

Takeaway

Healthcare follows money, not need. When market forces alone decide where doctors practice, care concentrates where it's most profitable — not where it's most necessary.

If economic barriers are the broad problem, insurance reimbursement rates are the sharp edge. Medicaid — the public insurance program for low-income Americans — pays doctors significantly less than private insurance. In some states, Medicaid reimburses only 60 to 70 cents for every dollar that Medicare pays. And Medicare already pays less than private insurers.

Think about what that means for a practice in a neighborhood where most patients have Medicaid. A doctor seeing the same number of patients, treating the same conditions, doing the same quality of work, brings in substantially less revenue. At a certain point, the numbers simply don't add up.

The result is predictable. Many physicians limit how many Medicaid patients they'll see. Some don't accept Medicaid at all. Research shows that roughly one in four physicians won't take new Medicaid patients, compared to fewer than one in ten for private insurance. This creates a painful irony: the program designed to give low-income people access to healthcare can actually make finding a doctor harder. Having a card in your wallet doesn't help if no one nearby will accept it.

Takeaway

Insurance coverage and healthcare access are not the same thing. A card in your wallet means little if the system doesn't pay enough for providers to accept it.

The good news is that some approaches are genuinely working. Community health centers — federally funded clinics specifically placed in underserved areas — now serve over 30 million Americans. They're required to see patients regardless of ability to pay, and they receive federal funding that helps close the gap left by low reimbursement rates.

Then there's the National Health Service Corps, which offers student loan repayment to providers who commit to working in shortage areas. It directly tackles one of the biggest barriers — the financial pressure that pushes new graduates toward wealthier communities. Telehealth has opened new doors too. When the nearest specialist is 90 miles away, a video consultation can bridge the distance in ways that weren't possible a decade ago.

These solutions share a common thread: they change the underlying incentives. Instead of expecting market forces alone to distribute healthcare fairly, they use targeted public investment to put providers where they're actually needed. None are perfect, and none have fully closed the access gap. But they prove an important point — healthcare deserts aren't inevitable. They're a consequence of specific design choices, and design choices can always be made differently.

Takeaway

Healthcare deserts are a design problem, not a fact of nature. Targeted public investment can redirect care toward need — but only when we decide to fund it.

The shortage of doctors in poor neighborhoods isn't a mystery. It's the logical outcome of a system where financial incentives pull care toward wealth instead of toward need. That gap translates directly into worse health outcomes — more preventable hospitalizations, more chronic disease, shorter lives.

But systems designed by people can be redesigned by people. Solutions already exist and they're working — they just need the investment to scale. Understanding how these gaps are created is the first step toward pushing for something better.