The Growing Divide: The Consequences of Fewer Rural Physicians

As the population in the United States continues to increase and grow older, more physicians are needed to keep the population healthy. Currently, there are almost 7,000 areas around the country with an inadequate number of primary-care providers, and with the current pace of population growth, the country could be short 95,000 doctors within the next decade. However, the lack of physicians is unevenly distributed across the country, impacting rural America the most. America is becoming more industrialized, but 97% of its land is still considered rural, and although 19.3% of the population live in rural areas, only 9% of physicians do. Nearly half of rural populations do not have adequate access to medical services.

There are several trends driving these statistics, one of which is the flow of physicians from rural to urban areas. The physicians leaving rural practice are usually relatively young (aged 45 or younger) and predominantly female. Other populations contributing to the exodus of rural physicians include international medical graduates, those not born in rural settings, and those working in a community far from metropolitan areas. There are numerous additional challenges encountered by physicians working in rural areas, including lower reimbursements for services, clinician lifestyle considerations, spousal career needs, and school quality. It was once believed that the lower socioeconomic status of rural areas was a direct cause for the drain of physicians, as rural populations tend to be poorer, older, and sicker than their metropolitan or suburban counterparts. This, however, was not supported by a study completed by the American Academy of Family Physicians, which has shown that economic demographics of served populations does not affect physicians’ decisions to leave rural areas. Two major reasons for leaving, as quoted by physicians, included lack of a nearby hospital and low population. Interestingly, the decision by one physician to leave also caused nearby healthcare workers to also consider leaving, causing an exponential drain in access to health care. The ability to retain rural physicians in remote communities that lack hospitals remains one of the biggest obstacles to expanding access to care.

There is a promising statistic for rural communities: 68% of physicians stay in the place they complete their residency. Despite the draining of doctors from rural areas, it is advantageous to entice young physicians and residents to spend their early years away from metropolitan and suburban areas. Unfortunately, specialties ultimately affect location, and only family practitioners are as likely to settle in rural areas as urban areas; all other specialties are more likely to settle in urban areas. There are additionally fewer and fewer general practitioners in the US as the medical field continues to grow more specialized, further driving doctors towards urban areas.

In order to attract the dwindling supply of general and family practitioners, rural communities must find innovative ways to appear more enticing. This is something that both federal and state governments have recognized, and numerous programs have been established to accomplish this goal. The most popular of these include loan forgiveness or repayment programs, which are especially appealing for recent graduates; in exchange for working in a rural community for a set number of years, physicians will either receive direct payment for medical school loans or have those loans forgiven. Some states, such as Arkansas, Minnesota, Montana, and Utah, have already implemented such programs. The federal government has several similar programs, some of which target specific groups, like the Indian Health Service Loan Repayment Program, which brings physicians to Native American communities.

Loan forgiveness programs are not the only options available for rural communities. Other initiatives such as J-1 visa waivers for international medical graduates have also been implemented to attract new physicians. In 2014, Missouri passed a law that allowed assistant physicians – medical school graduates who have not yet been placed in residency programs – to practice medicine in underserved areas under the supervision of a fully-licensed doctor. Although this does not count as a residency position, assistant physicians can work there indefinitely if they choose. However, as this program is still relatively new, other states are holding off on implementing a similar plan until long-term effects can be determined.

Due to the shortage of rural doctors, many communities have turned towards telemedicine, which does not require a physician to physically be with the patient. By offering access to physicians via video calls and emails, access to medical information, and remote diagnosis, telemedicine increases use of medical care in rural communities. Due to the delocalized nature of telemedicine, current issues for physicians include difficulties navigating multiple databases and staying informed of technological advances; both of these lead towards confusion and a lack of clear criteria when treating the patient. However helpful, telemedicine focuses on treating the symptoms caused by lack of physicians but fails to solve the underlying problems.

Despite the effort that rural communities have put into attracting physicians, it may not be enough to solve the lack of rural physicians. The central issues of dwindling rural hospitals and lack of funding hinder the efforts of communities to retain the doctors they desperately need. In order to combat structural barriers like fewer hospitals and poorer populations, rural areas will continue to need special programs to assist in the support of physicians; however, local, state, and federal governments will also need to support policies that increase access to service in these areas and reverse the flow of physicians leaving. One such example is the Affordable Care Act, which drove many uninsured individuals to receive health insurance. Before this policy took effect, hospitals would treat uninsured patients, but they would not be paid, which was incredibly detrimental to rural hospitals servicing largely uninsured populations. By increasing the percentage of insured patients, the ACA was able to decrease the rate of rural hospital closures.

Failure to support these policies has immediate and lasting consequences. In states that did not accept the expansion of Medicaid under the Affordable Care Act, 47% of rural hospitals lost money in 2015, compared to 35% of rural hospitals in states that did accept the expansion. To prevent the outflow of rural physicians, governments must first ensure that rural hospitals are able to operate and provide for patients, which includes increasing coverage of uninsured individuals and funding for rural hospitals. Although rural health does not concern most Americans, approximately a fifth of the population is at risk for limited healthcare access. In a nation divided along rural and urban lines, the problem of rural health cannot be ignored any longer. To combat the impending crisis and restore health access to these disadvantaged Americans, there must be more support for rural physicians and more funding for programs seeking to increase rural access to healthcare.