America Has Solved the Hardest Healthcare Access Problem Better Than Anyone Else — Here’s the Data

A bivariate analysis of 84,000 census tracts reveals that only 2% of Americans live beyond guideline-recommended access to emergency cardiac care.

There is a story that gets told about American healthcare with great confidence and very little data behind it. The story goes like this: American healthcare is uniquely broken, uniquely inequitable, uniquely cruel to the most vulnerable. Our peer nations have figured out what we have not. If only we would adopt their approach, millions of Americans who currently fall through the cracks would be caught.

I have written before about how this story is manufactured by those with incentives to tell it. I’ve also touched on publicly available data that doesn’t jibe with that narrative. Specifically, I’ve focused on an important proxy for health care access: whether a person having a heart attack can reach a hospital that can open their blocked artery before it is too late. Having a facility that can perform this type of a procedure requires significant infrastructure — a catheterization laboratory, trained interventional cardiologists, a specialized team available around the clock. It is therefore not uniformly distributed across geographies, and crucially, it is a procedure where we have excellent public data on exactly where it is being performed.

Access to PCI is not a perfect proxy for access to all medical care. But if a community has a functioning PCI program within reasonable distance, it almost certainly has the broader infrastructure — emergency services, hospital beds, advanced imaging, specialist coverage — that defines a functional healthcare ecosystem. The inverse is also roughly true: communities far from PCI tend to be far from the rest of advanced care as well. PCI access is a reasonable healthcare canary.

This post is a product of a conversation with the great journalist David Zweig who pushed me to refine my prior analysis and conclusions beyond what I had already done.

It was clear from the prior analysis at a US county level that America provides an impressive breadth of coverage, but we can get even more granular than the county level analysis I performed. The United States breaks up population into census tracts, geographic units even smaller than counties, and using this unit of analysis provides an even better approximation than prior.

My analysis demonstrates 92-98% of Americans are within actionable proximity to emergent cardiac care in the case of the single most common cause of death for adult Americans.

The United States has remarkably built a network of 1,248 Percutaneous Coronary Intervention (PCI)-capable hospitals — catheterization laboratories that can open blocked coronary arteries during a heart attack — and this network covers nearly the entire populated landscape of the country.

What PCI access actually measures

Percutaneous coronary intervention — threading a catheter through an artery to open a blockage — is the preferred treatment for ST-elevation myocardial infarction, the most dangerous type of heart attack. The procedure is time-sensitive in a way that is not metaphorical: every minute of delay translates directly into myocardial cell death, and the ACC/AHA guidelines set a hard target of 90 minutes from first medical contact to balloon inflation for patients who need transfer to a PCI-capable hospital.

That 90-minute window is not generous. It includes the ambulance dispatch, the drive to the patient, time spent on scene, and the drive to the hospital. When you apply the full prehospital time formula developed by Nallamothu and colleagues — accounting for all of these components — you get a clinically realistic picture of who can and cannot receive guideline-compliant primary PCI from where they live.

PCI access is also a useful proxy for healthcare infrastructure more broadly. If a community has a functioning cath lab within reasonable reach, it almost certainly has the surrounding ecosystem — emergency services, hospital beds, advanced imaging, specialist coverage — that defines a functioning healthcare system. The communities beyond PCI reach tend to be beyond reach of advanced care generally. It is a useful signal.

The map: what 84,000 census tracts show

Prior analyses of U.S. PCI access — most notably Nallamothu et al.’s 2006 paper in Circulation, which remains the methodological benchmark — used census tracts as the geographic unit, as I do here. A census tract averages about 4,000 residents and is designed to be relatively homogeneous in population and economic characteristics. Using tracts rather than counties eliminates the distortion that plagues county-level maps, where a single vast but nearly empty western county dominates the visual as much as a densely settled eastern one.

One additional refinement matters: population-weighted centroids rather than geometric centroids. The geographic center of a large western tract often lies miles from the nearest resident. Washoe County, Nevada — home to Reno and two PCI hospitals — has a geometric centroid 43.5 miles from the nearest cath lab, in a stretch of desert where essentially no one lives. Its population-weighted centroid, reflecting where Reno actually sits in the county, is 3.8 miles away. Use geometric centroids and you generate alarming-looking maps that misrepresent people’s actual experience.

Using population-weighted census tract centroids and the Nallamothu prehospital time formula, applied to 1,248 PCI hospitals identified from Medicare billing records (DRG codes 246–251), here is what the data show:

Seventy-nine percent of Americans live within 30 minutes. Another 19% are within 30 to 90 minutes. Just two percent — 6.4 million people — live beyond 90 minutes.

Who are the 2%?

The bivariate analysis — crossing prehospital time against population density — tells you something that a simple proportion cannot: who exactly is in that 2%, and what kind of problem they represent.

Of the 6.4 million Americans beyond 90 minutes of PCI, 4.7 million (73%) live in sparse-density census tracts, defined as fewer than 500 persons per square mile. These are communities with a median density of roughly 10 people per square mile — the Montana Hi-Line, the Nevada Basin and Range, the rural Mississippi Delta. A further 1.6 million (25%) live in moderate-density tracts that happen to be isolated from the existing catheterization laboratory network. And 108,000 — a number so small it barely registers — live in dense-density tracts beyond 90 minutes. Those 32 tracts are geographic anomalies: Hawaii, the Florida Keys, the Missoula corridor. They are not a healthcare failure. They are islands and mountains.

The 2% is not a sign of a broken system. It is the irreducible geographic residual of a continental nation — the people who have chosen, or whose families for generations have chosen, to live at the edges of a mapped and built landscape. No country at continental scale, no matter its healthcare financing model, comes close to eliminating this residual.

The sparse and >90 minute category — 4.7 million people at 10 persons per square mile — deserve access to emergency cardiac care. But the honest question is: what is the right tool? Building a full catheterization laboratory in a community of 2,000 people scattered across 200 square miles, staffed 24 hours a day by a team of interventional cardiologists, nurses, and technologists, is not a realistic or efficient deployment of scarce medical resources. Do you really want someone who performs this procedure 10 times a year working on you? For this population, pre-hospital or early fibrinolysis followed by transfer to a high volume PCI center — the pharmacoinvasive strategy — is likely the best solution.

The moderate-density category — 1.6 million people in 409 tracts — is a reasonable policy target for infrastructure investment. These are communities with enough population to plausibly sustain a reasonable-volume PCI program. They tend to cluster in central Appalachia, the rural Southeast, and isolated secondary cities in the Mountain West. This is where targeted expansion, (perhaps through physician-owned facilities freed from the ACA’s ban on physician hospital ownership), could meaningfully close the remaining gap.

2% is not a failure. Trying to get lower would be.

Policy makers should be honest about the implications here.

There is no version of a free society in which every person who chooses to live at 10 people per square mile in the Nevada desert, the Montana plains, or the Alaska interior also has a cardiac catheterization laboratory within 90 minutes. This is not a failure of will, or financing, or equity. It is geography and physics. Drive times are what they are. People who move to the middle of nowhere do not surrender their right to emergency care, but they do accept certain realities about what is and is not proximate to them — realities that no federal program has ever been able to fully repeal.

What is a failure — a genuine, correctable misallocation of resources — is spending billions of federal dollars trying to push that number below 2% through mechanisms that demonstrably do not work. The Critical Access Hospital program has cost Medicare tens of billions in cost-based reimbursements over three decades. The Rural Emergency Hospital designation, the rural GME carve-outs, the physician shortage area designations that classify geographically urban hospitals as rural to capture federal payments — all of this spending has moved the needle by a fraction of a percentage point. The people beyond 90 minutes today are essentially the same proportion as they were in 2000, when Nallamothu first measured them.

The resources spent trying to get from 2% to 1.5% through fixed infrastructure in places that cannot sustain it are resources not spent in more productive pursuits like a rural focused air transport network that could realistically serve them, or on primary care physicians in rural communities who might prevent some of those heart attacks in the first place.

There is a version of rural health policy that is honest about what is achievable, directs resources toward solutions that match the actual problem, and stops using the rural access narrative as a justification for funding streams that primarily benefit everyone but the patients in need. That version does not currently exist. The current version maintains the narrative because the narrative maintains the funding.

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Canada: The Comparison that Matters Most

Every international healthcare ranking that places the United States near the bottom of high-income nations implicitly or explicitly holds up Canada as a comparator worth emulating. The Commonwealth Fund, the most widely cited source of these rankings, treats universal insurance coverage as the primary measure of access. Countries with national insurance systems — Canada prominent among them — score well almost by definition.

But insurance coverage and geographic access to care are not the same thing, and nowhere is the gap between them more apparent than in emergency cardiac care. For the Canadian comparison, I apply the full Nallamothu prehospital time formula to Canada’s 293 census divisions and its 41 PCI hospitals (identified through CIHI, CorHealth Ontario, the BC Cardiac Registry, Alberta APPROACH, and equivalent provincial cardiac network directories):

9.1 million Canadians — 24.5% of the population — live beyond 90 minutes of total estimated prehospital time from a catheterization laboratory.

The comparison between the two countries holds regardless of which methodology you use:

Whether you measure raw driving time or total prehospital interval, whether the gap is three-fold or ten-fold, the conclusion is the same: the United States provides significantly greater geographic access to emergency cardiac care than Canada does. This is not a close call. It is not within the margin of methodological uncertainty. It is a large, consistent, and robust disparity that persists across every reasonable analytical approach.

And it is not because Canada is vast. Canada’s 37 million people live almost entirely within 125 miles of the U.S. border, in a narrow temperate corridor. The access problem is not geographic inevitability — it is infrastructure insufficiency. 41 PCI centers for 37 million people.

Every Canadian living beyond 90 minutes of a PCI hospital falls below the U.S. sparse threshold of 500 persons per square mile — meaning Canada’s entire unserved population would be classified as rural by American standards. This is true even in some of Canada’s densest census divisions. Eleven census divisions in Canada’s top density tier — including Francheville (Trois-Rivières), Sherbrooke, and Nanaimo, totaling 1.3 million people — exceed 90 minutes of total prehospital time under the Nallamothu formula. These are not remote communities. They are mid-sized cities in historically settled regions of North America. And yet, a STEMI patient in any of them with universal health insurance is categorically worse off than a STEMI patient in an uninsured rural Nevada community 25 minutes from Renown Regional Medical Center.

A methodological note: the Nallamothu formula assigns urban speed parameters (35 mph average driving speed) to census divisions above Canada’s dense threshold. For intercity highway drives — such as Trois-Rivières to Quebec City — this likely understates actual travel speed, meaning the Canadian prehospital times presented here are, if anything, conservative. The true access picture may be somewhat better than what we report, but this bias makes the comparison more generous to Canada, not less.

What the data tells us

The U.S. PCI access picture that emerges from this analysis is not a story of failure. It is a story of remarkable achievement — 1,248 hospitals, distributed across a continent-spanning nation of 335 million people, providing timely drive-time access to 98% of the population.

The U.S. is genuinely without peers. Every international comparison of healthcare access implicitly assumes the countries being compared are meaningfully comparable. They are not — at least not for this question. The United States is the third-largest country in the world by land area and the third most populous. No high-income democracy comes close to combining both. The United Kingdom has 68 million people in an area smaller than Oregon. The Nordic countries together have fewer people than the greater New York metropolitan area spread across a landmass that is mostly accessible by road. These countries face no meaningful analog to the American geographic access problem.

The countries that do approximate the U.S. in scale — Russia, China, India, Brazil — fail so comprehensively on PCI access that no meaningful comparison is possible. Russia has perhaps 100 PCI centers for 144 million people across 11 time zones. China’s cath lab infrastructure is heavily concentrated in coastal cities. India and Brazil have dramatic urban-rural gradients at a severity that makes rural Nevada look well-served. These are not peer comparators. They are cautionary tales about what actually happens when healthcare infrastructure is insufficient at continental scale.

The 2% — 6.4 million people — that are genuinely far from critical access to care do deserve attention, but they need solutions based in reality not utopia. The 1.6 million in moderate-density isolated communities may be worthy of targeted infrastructure investment, ideally through models (physician-owned facilities, rural-specific certificate of need reform) that can be sustained without permanent federal subsidy. Those In in deep rural areas deserve better access in the form of better pharmacoinvasive protocols, better air transport access, and better primary care — not another round of cost-based reimbursement to a Critical Access Hospital that cannot staff a cath lab anyway.

And the Canadians who are held up as evidence of what universal coverage achieves deserve an honest accounting of what their system has and has not built. Universal Medicare-For-All insurance has built a PCI network that does not serve nearly a fifth of their population within the accepted guideline window for life saving cardiac care. The patchwork American system — the one that is ranked last by the Commonwealth Fund — has.

A country that achieves timely emergency cardiac access for 98% of a continental population of 335 million has not failed its citizens, rural or urban. A country that gives 100% of its citizens a national insurance card, but leaves 24.5% of its population beyond a critical window of medical care is not a model of success. It is a failure.

Anish Koka (@anish_koka on X) is a cardiologist in Philadelphia. He writes on medicine and health policy and co-hosts The Doctors Lounge podcast. Interactive maps are available at anishkoka.github.io/pci-access-maps.

For detailed methods, data sources, and limitations, see the technical companion.

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Data sources: U.S. Census Bureau 2020 Census tract data · Medicare Inpatient Provider data (DRG 246–251) · Statistics Canada 2021 Census · CIHI Cardiac Care Quality Indicators · Provincial cardiac network directories (CorHealth Ontario, Alberta APPROACH, BC Cardiac Registry)