Rural America doesn’t have enough doctors. Rural areas have roughly 30 physicians or specialists for every 100,000 people, while urban areas have 263, according to a recent survey from the National Rural Health Association.
This shortage means those living outside the nation’s major cities face long wait times or lengthy commutes to get the healthcare they need, increasing the likelihood that they could die from preventable diseases.
“It’s already not that easy in rural areas to access care given transportation issues, and if there aren’t any (health care providers) in a rural area, you may need to drive to the nearest city, and that makes that access problem worse,” said Judith Garber, senior policy analyst for the Lown Institute, a healthcare think tank headquartered near Boston.
Experts who study this problem say solutions exist, but fully staffing the rural America’s hospitals and doctors offices requires state and local governments and the healthcare community to work together.
Above all, solving the shortage will require an investment of time, attention and — especially — money.
The consequences of the rural doctor shortage are dire.
“These disparities that are at the root of why rural Americans suffer disproportionately high rates of diseases like diabetes, stroke and heart disease,” said Dr. Bruce Scott, a Kentucky otolaryngologist and the president-elect of the American Medical Association.
Studies have repeatedly shown that people in rural areas are more likely to die of preventable diseases than their urban counterparts. In March, for example, the U.S. Department of Agriculture’s Economic Research Service found the mortality rate for chronic diseases like kidney disease, hypertension and diabetes is 43% higher in statistical areas with less than 50,000 people.
Why is this a problem?
The forces behind the shortage are legion. The whims of young doctors play a role, said Sara Wallbollinger, director of strategic development for the New York State Association of Rural Health.
“A young person entering a medical field, they want to live somewhere where there are other young professionals and things to do, and many times they’re looking to go to a fun place where there’s a lot of action, which is usually a city,” she said.
But the problem is largely an economic one, experts say. Rural areas are less appealing to doctors who are reimbursed per patient or per procedure, because small towns have a smaller patient population.
Scott noted that medicare reimbursement rates have largely stagnated while inflation has pushed up costs for private practices like his. The American Medical Association found the value of medicare reimbursements dropped 29% since 2001 when adjusted for inflation.
As his costs spike, Scott worries he might have to let some of his employees go, or stop offering services his patients depend on.
“When doctors lack the resources to take care of our patients, we’re going to have to make a difficult choice,” he said. “Do we not invest in new equipment? Do we reduce employees? Do we stop accepting medicare patients or limit them?”
Other issues include the closure of rural hospitals, a slow-burning problem that accelerated during the coronavirus pandemic.
A 2023 study from the American Hospital Association found that 130 rural hospitals closed between 2010 and 2021, and even more are dropping specialty services like cancer and birthing centers, Scott said.
Fewer rural hospitals means fewer residency programs training doctors outside of major urban areas.
What to do about it
Experts note there are a number of solutions. The federal government already has programs that forgive a portion of a doctor’s medical school loans if they practice in underserved areas, Garber noted. Expanding those loan forgiveness programs is a possible solution, she said.
“There’s about 2,800 primary care practitioners in this program, and 680 of them are doctors,” she said, citing federal statistics. “That doesn’t seem like a lot.”
Some experts also argue the reimbursement system for doctors needs to change. Giving healthcare professionals a set salary could lure more doctors and nurses away from the nation’s large cities.
Doctors are likely to practice near their home city, which means providing students at rural high schools with the resources and the encouragement to pursue medicine could draw more medical professionals to sparsely populated regions.
“The biggest thing to do is find individuals early enough that are interested in and want to practice in underserved areas, and support them through their education,”, said Brianna Sheppard, director of the West Virginia Health Education Center.
That means introducing them to practicing physicians or other medical professionals, and giving them the tools they need to succeed, she said.
“We are trying to encourage medical schools to be more proactive about placing medical residents in rural communities,” Wallbollinger said. “So they already have friends in the small town and it doesn’t seem like such a burden to stay there.”
Various organizations are already taking these approaches, Sheppard said, but she and other experts interviewed for this article say the programs need to be expanded.
Systemic problems also need to be addressed, Wallbollinger said. Rural high schools, for example, are less likely to have advanced placement courses, she said.
That means if you went to an urban or suburban high school “you would already be further ahead when you get to college,” Wallbollinger said.
