The United States has long been plagued by geographic health inequities. Rural Americans exhibit higher rates of chronic and life-threatening diseases, obesity, infant mortality, suicide, and mental health problems, according to the Stanford University School of Medicine. Only 10 percent of U.S. doctors practice in rural areas—there are only 65 primary care physicians per 100,000 people, compared to 105 in urban and suburban areas—despite the fact that such areas are home to 20 percent of the U.S. population. Rural residents are also less likely to have Medicaid, employer-provided health insurance, or prescription drug coverage; in particularly isolated areas, they may struggle to access medical facilities for follow-up or emergency care.
Rural areas have always struggled to attract and retain qualified physicians; doctors, just like lawyers and artists, often prefer to live near the excitement and professional opportunities that cities offer. But a paper published last week in the Journal of the American Medical Association identifies one factor that may be worsening the trend: Doctors are increasingly married to other well-educated professionals who may have less geographic flexibility.
In 1960, only 8.8 percent of doctors had a "highly educated" (as defined by having a graduate degree) spouse. By 2010, that figure had shot up to 54.1 percent. Some of this is attributable to the fact that there are more female physicians today than there were in 1960, and female doctors are more likely than male doctors to have a highly educated spouse. But even male doctors today are more likely to have a spouse with a graduate degree than they were 50 years ago. The paper's authors hypothesize that doctors with well-educated spouses may be unable to relocate to rural areas due to their spouses' careers—and, in fact, doctors with a highly educated spouse are less likely to work in a rural area.
While this factor explains only a small part of the medical staffing challenges in rural areas, Doug Staiger, an economics professor at Dartmouth College and one of the study's authors, told Kaiser Health News that "[a]nyone who's tried to recruit in rural areas—[it's] hard to overcome given the lack of jobs."
It is important that we recognize the implications of the enormous benefits that befall the children of two wealthy, well-educated parents.
Doctors' increasing propensity to marry people with a similar level of education or income—other doctors, lawyers, professors, etc.—is something that researchers call assortative mating, and it's been on the rise in the developed world for decades. Before the 1960s, marriage was all about specialization: One spouse (typically a man) went to work and brought home a paycheck, while the other spouse took care of the children and the home. But as the women's liberation movement empowered more and more women to pursue higher education and seek employment outside the home, and as technology (washer/dryers, dishwashers, pre-made meals) reduced the time it took to accomplish household tasks, the purpose of marriage gradually changed. Today, by and large, people look for partners with similar interests and who they enjoy spending time with, partners who will be a good companion in the decades to come. Often, that translates to marriages where both spouses have similar backgrounds and comparable levels of education or income.
"These days, an investment banker may marry another investment banker rather than a high school sweetheart, or a lawyer will marry another lawyer, or a prestigious client, rather than a secretary," economist Tyler Cowen wrote for the New York Times' Upshot last December. "Whether measured in terms of income or education, there are more so-called power couples today than in the past, one manifestation of a phenomenon known as assortative mating, or more generally the pairing of like with like."
Assortative mating, for all that it reflects positive changes in gender norms, is blamed for more than just rural doctor shortages. In particular, many economists argue it has contributed to increasing income inequality. "Marrying up" has ceased to be a viable strategy for economic mobility, and today's "power couples" are apt to pool their substantial earnings and resources to ensure that their children have the best schools, the best soccer coaches, the best piano teachers—decisions which serve to increase their children's prospects, and, in the process, to exacerbate inequality. A 2015 paper attributes one-third of the rise in U.S. income inequality to decisions around marriage, divorce, and female labor force participation.
There's not much that can be done about assortative mating from a policy perspective—it's hard to imagine any politician advocating for legislation that forbids people with graduate degrees to marry other people with graduate degrees. But it is crucially important that we recognize the implications of the enormous benefits that befall the children of two wealthy, well-educated parents—and how those benefits have bypassed most low-income children completely.