A Case for Full-Service, Low-Cost, Non-Profit Community Veterinary Care Centers
by Bob Christiansen
Free download from www.bocafund.com.
“Financial forces and technological innovation are separating pet owners and veterinary practices into have and have-nots,” Bob Christiansen begins in Is the Veterinary Profession Serving All Companion Animal Medical Needs in America Today?
“There is no doubt,” Christiansen writes, “that America has the best companion animal veterinary care money can buy, with the latest advancements in medical technology.”
However, Christiansen argues, “Fees for veterinary services have risen far beyond the market median, to a point that makes veterinary care out of reach for over half of America’s pet households.”
U.S. vets serve only 37.4% of all dogs & cats
Specifically, as one of Christiansen’s illustrative tables is headlined, “United States companion animal veterinary practices only serve 37.4% of all dogs & cats.”
Is the Veterinary Profession Serving All Companion Animal Medical Needs in America Today? is hardly the first time that Christiansen has pointed out in depth and detail that economic issues associated with social inequality are a major cause––perhaps the biggest––of practically all of the other public issues associated with dogs and cats.
Initially a San Diego dog trainer, Christiansen in 1995 authored Choosing and Caring for a Shelter Dog (1995). Four years later Christiansen delved into dog and cat population demographics and related economic issues in Save Our Strays: How We Can End Pet Overpopulation and Stop Killing Healthy Cats & Dogs (1999).
Author “coined the phrase ‘live release rate'”
Christiansen claims to have “coined the phrase ‘live release rate’” in Save Our Strays to show the good work animal control agencies do to save animal lives.”
Also known as the “save rate,” the “live release rate” is simply the inverse of the euthanasia rate. In any form, by any name, it is the most backward, misleading, and ultimately self-defeating statistic ever to afflict animal care-and-control work.
Use of “live release rate” presumes that all animal shelter intakes and exits are of equal value in serving the community; that the primary purpose of animal care-and-control agencies is to “save” as many animals as possible, even if it requires “rehoming” them to suffer neglect and abuse; and that protecting humans and other animals’ lives by euthanizing dangerous dogs, the primary purpose for which the public pays taxes to fund animal care-and-control agencies, is detrimental, since it lowers the “live release rate.”
Christiansen & Peter Marsh identified poverty as root cause of shelter killing
Fortunately, Save Our Strays also helped to impress upon the animal care-and-control and humane communities the importance of making inexpensive and even free spay/neuter service available to low-income pet keepers.
In particular, Christiansen and fellow dog and cat population analyst Peter Marsh demonstrated through separate studies of data from California, Georgia, New Hampshire, New Jersey, and North Carolina that the poorest counties in each state killed dogs and cats at up to four times the rate of the richest.
Marsh, cofounding an organization called Solutions To Overpopulation of Pets, helped to introduce targeted low-cost spay/neuter programs which cut shelter animal intake and killing in New Hampshire by approximately 80% between 1992 and 2003.
Targeted low-cost spay/neuter continued to keep the numbers down even as the New Hampshire human and pet populations grew by about 15% during the first decade of the 21st century.
Low-cost nonprofit veterinary entrepreneurs
Christiansen, meanwhile, moved to Atlanta in December 2000 to become executive director of the DeKalb Humane Society. There Christiansen met veterinarian Amy Orlin. Christiansen and Orlin went on to co-found the Atlanta Animal Alliance.
Investing $200,000 of their own money, Christiansen and Orlin went on to found Project CatSnip in 2002, which Christiansen and Orlin describe as a “low-cost spay/neuter that has performed more than 100,000 surgeries.”
In 2008, Christiansen and Orlin founded yet another entity, WellPet Humane, in their words “a full service affordable veterinary program that targets low-income pet owners,” serving “more than 30,000 pet owners and 50,000 pets annually.”
Christiansen and Orlin sold WellPet Humane and started the Boca Fund.
Says the Boca Fund web site, “We believe that with the sale proceeds we can do more for the veterinary needs of indigent companion animals by becoming a granting foundation with the goal of providing seed money to establish Community Veterinary Care Clinics.”
Nonprofits “fill a gap in services”
Writes Christiansen, “The role of nonprofits is to fill a gap in services not otherwise provided by government or private for-profit businesses.”
Such a gap is widening as regards veterinary care.
“The medical needs of low-income and ethnic pet owners, those owners with little savings, living paycheck-to-paycheck, cannot be met by profit-maximizing for-profit and corporate veterinary clinics,” Christiansen emphasizes with table after table and statistic after statistic.
“The needs of the subset of pet owners who are financially struggling, with little discretionary income can only be served by nonprofit, donor subsidized, full-service clinics targeting qualified low-income pet owners,” Christiansen argues.
This is because, Christiansen recites, “Upper-income families were the only income tier able to build on their wealth from 2001 to 2016, adding 33% at the median. On the other hand, middle-income families saw their median net worth shrink by 20% and lower-income families experienced a loss of 45%”
“Half of American households cannot afford vet care”
Therefore, Christiansen explains, “Half of American households, with little discretionary income, cannot afford [either] basic or critical veterinary care.”
Consequently, “There is currently a rise in economic euthanasia,” even as shelter killing for other reasons is at the lowest rate ever.
A related trend, Christiansen finds, is that “Veterinary medicine remains one of the least diverse professions in the United States. The profession’s ethnicity is 89% white, 5% Latino, 4% Asian, 2% black.”
This scarcely reflects rates of pet-keeping. According to American Veterinary Medical Association data, 64.7% of white households keep pets, as do 61.4% of Latino/Hispanic households, and 36.9% of African-American households, whose lower rate of pet-keeping probably reflects a much lower rate of home ownership.
But as Christiansen demonstrates with a map of veterinary clinic locations in Brooklyn, New York, about 90% of all veterinary practices are located in affluent mostly white neighborhoods. Almost none are in low-income neighborhoods, regardless of neighborhood ethnicity.
Cost of vet care rising at twice the rate of inflation
Christiansen sees publication of a 1999 report entitled The Current and Future Market for Veterinarians and Veterinary Medical Services in the United States as “a seminal moment and a call to action in the veterinary profession. It forecast trouble if changes were not enacted regarding stagnant veterinary incomes that were not keeping pace with other professions and strongly recommended increasing prices.
“Veterinarians got the message loud and clear,” Christiansen observes, “and raised prices on average 4.5% every year since, according to the Bureau of Labor Statistics. But suddenly everyone started wondering why client visits were dropping.”
Explains Christiansen, “Veterinary services costing $100 in the year 1997 would cost $287.38 in 2021 for an equivalent purchase. Compared to the normal U.S. inflation rate of 2.15% during this same period, the cost would be $164.31.”
Oligopoly: not a board game
Such an extraordinary rate of fee increase is possible, Christiansen continues, because “The companion animal veterinary business is an oligopoly, a state of limited competition, in which a market is shared by a small number of firms that join together, either explicitly or tacitly, to set or fix prices within small degrees of each other in order to achieve above normal market returns.”
Driving this trend, Christiansen postulates, is “a strong desire to imitate human medicine,” but “without the prevalence of insurance” to help cover that bills, “and limited government financial involvement.”
Perhaps the biggest single factor influencing rising prices for veterinary services, Christiansen believes, is that “Limiting the supply of veterinarians,” by limiting veterinary school admissions, “drives price.”
Costs more to become a vet than to become a doc
Therefore, “Since the year 2008 the student cost for a Doctor of Veterinary Medicine degree has skyrocketed,” becoming “more costly than other professional medical education. Student net tuition as a percent of total education rose from 26% in 1990, to 30.1% in 2000, to 37% in 2010, up to 47% in 2017.”
Meanwhile, “The average state is spending 23% percent less per student than before the  recession. To compensate for this loss, class sizes have increased, especially with higher-paying non-state residents. In addition, universities increased prices by an average of 5.2%, higher than the cost of living.
“The average veterinary student debt [now] averages about $183,000,” with some veterinarians owing as much as $300,000 before they enter paid practice.
Simultaneously, veterinarians have largely lost to online sellers the revenue they once realized through maintaining in-house pharmacies.
Economic pressure encourages more veterinarians to specialize, helping to drive veterinary salaries up from circa $60,000 per year in 1995 to nearly $100,000 per year as of 2020.
But this leaves ever fewer general practice veterinarians to serve the less affluent half of pet keepers who cannot afford high-priced specialty care.
As of 2020, Christiansen reports, there were 118,624 practicing veterinarians, of whom about two-thirds were female. Nearly 80% worked in private clinical practice with companion animals,” a marked change from circa 1990, when about two-thirds of veterinarians were male, and about half worked in agriculture.
Since 84% of applicants to veterinary schools are female, the gender balance of the profession is soon to tip even more dramatically.
At the same time, though, working conditions for young veterinarians are likely to become increasingly difficult.
Currently, writes Christiansen, “The average [animal] hospital has 2.5 veterinarians working with five techs and three [other] support staff. More than half of U.S. veterinary practices are one-to-two doctor practices,” typically owned by older male vets, approaching retirement, “while 20% are part of firms with more than 100 total employees.”
“Relative to the amount of training they receive compared to other professions, starting salaries for practitioners have been lacking for decades,” Christiansen says, “with most of the higher incomes going disproportionately to practice owners.”
The 20% of veterinary practices owned by large private equity consolidator groups, Christiansen says, “account for about 40% of billings.”
These companies’ market share “is growing and eventually will be 50% of total practices that account for 75% of transactions,” Christiansen notes.
Private equity firms taking over
“Most prognosticators [looking at veterinary revenue] see a growing, aging pet population,” Christiansen observes.
“Wall Street private equity and hedge funds see a great opportunity to make money in the veterinary profession. They are attracted to a fragmented, unregulated, recession proof market, with consistent historical and projected growth.
“Fueling the transition,” to corporate ownership, Christiansen sees, “are aging practice owners who are looking to exit and current practitioners who want to work less and are not interested in the demands of practice ownership. Compounding the problem is a growing preference among graduating veterinarians to work for a veterinary services platform, rather than start their own practice or acquire an existing hospital. This all adds up to an attractive investment market ripe for corporate consolidation and takeover.”
Already, Christiansen notes, “private equity firms have bought thousands of veterinary practices and rolled them up into nationwide chains. Just four of these chains have almost 1,500 locations,” as well as the major pet insurance companies.
Vet needs “cannot be met by profit-maximizing”
But, Christiansen again points out, “The medical needs of low-income pet owners, those owners with little savings, living paycheck-to-paycheck, cannot be met by profit-maximizing, for-profit and corporate veterinary clinics. The needs of this subset of the pet-owning population can only be served by nonprofit, donor subsidized, full-service clinics targeting low-income pet owners.
“Where existing full-service, non-profit clinics have been opened for years, local veterinary practices at first protested,” Christiansen says, with his own experience in partnership with Amy Orlin furnishing a close-to-hand example, “but soon found their revenue were not affected. And, rather than send critically ill patients away due to affordability issues, for-profit clinics referred them to a non-profits for treatments.”
To make the introduction of more nonprofit, donor-subsidized, full-service clinics work, Christiansen emphasizes, nonprofit clinics must “income qualify” patients to ensure that the nonprofit services are not exploited by affluent pet keepers seeking bargain care.
Christiansen cites the success of two British veterinary charities, the Blue Cross for Pets, founded in 1897, and the People’s Dispensary for Sick Animals, founded in 1917.
Christiansen might also have mentioned Dogs Trust, founded as an anti-vivisection society in 1891, which as the National Canine Defence League provided similar services through 13 London-area veterinary clinics. As Britain rose in affluence and the need for donor-subsidized nonprofit veterinary care declined, the National Canine Defence League transitioned into a dog-and-cat rehoming agency, closing its last clinic in 1987, now operating 19 rehoming centers in Britain and Northern Ireland.
“These organizations enjoy good relationships with veterinarians in Great Britain. They even subsidize a portion of emergency care at for-profit clinics when decisions need to be made promptly,” Christiansen says.
British veterinarians “know that these clients have limited resources and would not be able to access veterinary care any other way. The main reason these programs have been successful,” Christiansen concludes, “is that the charities income qualify.”
Is the Veterinary Profession Serving All Companion Animal Medical Needs in America Today? “is dedicated to the memory of Kelly Farrell DVM.”
Christiansen and Orlin remember Farrell as “a humanitarian veterinarian who worked tirelessly to help tens of thousands of animals with her non-profit work in Roanoke, Virginia, and Jacksonville, Florida.”
Farrell committed suicide in 2017.
Christiansen and Orlin say nothing otherwise about Farrell, and little about veterinary suicides.
Farrell’s sister Kathleen Sclafani told ANIMALS 24-7 in January 2023 that, “Kelly’s work is what kept her going despite the depression she struggled with throughout her lifetime. It is misleading to attribute her suicide to anything having to do with her career.”
However, the economic factors identified by Christiansen in Is the Veterinary Profession Serving All Companion Animal Medical Needs in America Today?, and the emotional stress associated with “economic euthanasia,” have been identified in a variety of studies and case histories as common contributing reasons for veterinarians killing themselves, albeit trailing failed personal relationships.
Trends developing for decades
Many of the points discussed in Is the Veterinary Profession Serving All Companion Animal Medical Needs in America Today? turned up decades earlier in a 1994 national survey of pet-keepers, veterinarians, and humane societies conducted by ANIMALS 24-7, sponsored by the Spay/USA division of the North Shore Animal League America.
ANIMALS 24-7 found then that low-income people made up nearly half of the clientele of the low-cost sterilization programs then operating.
Further, when low-cost sterilization was available, low-income people sterilized their dogs and cats at twice the rate one would expect from their numbers as a percentage of the general population.
When low-cost sterilization was not available, low-income pet keepers reported dog and cat sterilization rates running at least 11% below the national norms.
Low-income pet keepers had approximately the same rate of dog ownership as other Americans, but reported owning 21% more male cats than the national norm; 36% more female cats; and 29% more cats overall.
The greater rate of cat ownership may have directly reflected the lower level of sterilization.
Price resistance in all income brackets
Lower income people were also more than twice as likely to abandon animals at shelters than middle or upper income people, but were not significantly under-represented among either adopters of shelter animals, or patrons of veterinary clinics in general.
The major reason for this appeared to be that price resistance to veterinary procedures kicked in at virtually the same level among people in all income brackets, with Afro-American and Hispanic pet keepers somewhat less likely than white people to balk at the cost of a procedure.
Poor people, in general, would pay the same prices as anyone else to help a pet, if they had the money, while many more affluent people would put off a non-essential veterinary procedure if the cost exceeded the equivalent, in 1997 dollars, of $100.