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Addressing Rural Health Worker Shortages Will Improve Population Health And Create Job Opportunities

The United States is facing a nationwide health care worker shortage. In rural communities, this crisis is worse and more widespread. According to calculations by the Joint Economic Committee (JEC) Democratic staff, 91% of all rural counties and 96% of rural counties in New Mexico face a shortage of primary care physicians[1]. These shortages harm both the health and economic well-being of rural communities, with Tribal communities facing some of the largest shortages and the most significant impacts.  

Addressing the rural health worker shortage and creating pathways that lead to health care careers in these areas are critical to protecting and improving the health and economic stability of rural communities. The Pathways and Health Careers Act, introduced by JEC Chairman Martin Heinrich, would reauthorize and expand a proven training model that can help meet the medical workforce needs of rural areas. Americans deserve access to quality health care regardless of where they reside, and addressing the rural health worker shortage will mark a significant step towards that goal.

[1] Based on data from the Health Resources and Services Administration’s primary care Health Professional Shortage Area data. Health Professional Shortage Areas (HPSAs) are geographic areas, populations, or facilities that have a shortage of primary, dental, or mental health care providers. We included a county as experiencing a shortage if either the county as a whole, or a population or facility in that county had a primary care shortage.

The demand for physicians is growing, while supply challenges are worsening the shortage in rural areas.

The health care workforce shortage is being driven by growing demand for providers coupled with an insufficient supply of medical professionals. The main driver of growing demand is the United States’ aging population, as older Americans require large amounts of medical care. Rural areas already have a higher rate of older residents aged 65 and older (19%) than urban areas (15%). Because the share of people aged 65 and older is expected to grow by more than 40% by 2034, these rates—and disparities—may continue to grow. 

Challenges in the training and distribution of doctors are preventing supply from meeting rising demand in rural areas. Rural areas often struggle to attract and retain those physicians who prefer to work in larger cities or who need work opportunities for their spouses. Many rural providers are often people who grew up or attended school in rural communities themselves. However, the number of medical school entrants from rural areas declined by 28% from 2002 to 2017, a sign that rural provider shortages could get worse in the future, absent efforts to close the gap.

This specific shortage in rural areas is part of a broader problem where the number of physicians is not rising fast enough to meet the growing need for doctors. This shortfall is compounded by the flawed residency system, which artificially caps the number of new doctors trained each year, distorting where doctors end up practicing. The United States also makes it particularly difficult for international medical graduates, who work disproportionately in rural areas, to obtain U.S. medical licenses, further restricting the supply of providers.

Health provider shortages harm peoples’ health and hold back rural economies.

The shortage of health care providers has significant negative impacts on the health and economic security of rural areas. Fewer available physicians led to a 24% growth in wait times between 2004 and 2017, and hospital closures can force rural patients to travel 20 additional miles on average to receive common care services, and nearly 40 miles further to receive alcohol or drug treatment services. Longer wait times and hospital closures can cause patients to delay care due to travel or time restrictions, leading to worse health outcomes and greater mortality, as patients suffer from avoidable illnesses due to lack of treatment.

Being forced to travel extended distances also has individual economic costs, including more time spent missing work, difficulty securing child and family care arrangements, and higher spending on gas, food, and lodging. Additionally, greater rates of illness in a community can harm productivity, costing the economy hundreds of billions of dollars annually due to absences or reduced productivity from working while sick, especially as rural workers are less likely to have access to paid sick leave than workers who live in urban areas. When communities lose physicians, the broader economy takes an even larger hit because doctors play a significant role in their local economy that supports multiple jobs and brings in added tax revenue.

Staffing shortages exacerbate any rural hospital closure, though the closures are more concentrated in states that did not accept federal funds to expand Medicaid under the Affordable Care Act. Between 2010 and 2021 a total of 136 rural hospitals and health systems closed, and nearly 3 out of 4 of these closures were in states that either refused to expand Medicaid or where expansion had only been in place for less than a year. This additional federal funding is important for helping rural hospitals stay in business and maintain their staffing by decreasing the local uninsurance rate, so Medicaid expansion is a straightforward way to prevent closures and maintain staffing. Keeping these facilities open also keeps their health workforce in place, avoiding the damaging cycle where closures cause workers to leave rural areas while the remaining health systems get overwhelmed and communities bear the costs.

Health worker shortages in rural areas pose particular risks to pregnant women, communities of color, and those on Tribal lands.

The shortage of health workers in rural areas makes it even harder for many people who already face unequal access to health care. Only 4.3% of OBGYN and 1.4% of neonatal care physicians live in more rural areas, despite those areas being home to 10.6% of all women ages 15-49. This mismatch increases pregnancy risks for mothers in rural communities since a lower level of provider accessibility in a region is correlated with higher rates of maternal mortality.

People of color and those living on Tribal lands are even more likely to feel the burden of lower access to health care in rural areas. Almost one in four rural Americans is a person of color, and rural communities of color usually experience the biggest health risks, including higher Black maternal mortality rates, in part because of their limited access to health care. This is also true on Tribal lands, where the Indian Health Service (IHS) has long struggled with staffing shortages. For example, IHS estimated that the provider vacancy rate was 25% in 2017 with rates as high as 31% in certain geographic areas. These difficulties filling roles are in part driven by lower salaries, housing shortages, and the general challenges of recruiting providers to rural locations.

Grow your own programs can create career pipelines into key health occupations for people from rural areas.

Individuals with rural backgrounds are more likely to return to these areas to practice medicine.  Surveys have found that 30% to 52% of providers with rural backgrounds return to rural areas to practice, compared to only 11% of doctors overall. Because of this, programs that focus on empowering rural students to pursue medicine and return to rural areas, known as “grow your own” programs, can be a key component of bolstering the rural health care workforce.

Many medical schools have already begun to adopt this approach, with schools in largely rural states such as Alabama and Mississippi creating programs and scholarships to recruit and retain rural students to practice medicine. These programs have already shown signs of success: Alabama’s program has seen most graduates go on to practice in the state, mostly in rural areas. Mississippi’s program produced 66 rural primary care doctors as of the summer of 2022, and with more in the pipeline should have 220 doctors in place by 2030. While participants are only required to work in a rural area for one year after graduation, nearly 85% of graduates remain in rural areas after their term of service is over.

Because of the success seen with these programs, and the critical need to increase the number of rural physicians, expanding access to these programs to reach more students could play an important role in reducing the rural health worker shortage.

Other initiatives that address the health worker shortage can supplement grow your own programs.

In addition to grow your own programs, a number of other initiatives have been introduced to help reduce the shortage of health workers both in rural areas and across the country. For example, existing national programs include the National Health Service Corps, which incentivizes newly trained doctors to work in high-need areas in exchange for student debt relief. Additionally, to address the impact of limited residency programs, the Teaching Health Center Graduate Medical Education Program provides for residency training in community health centers, with a focus on rural and high-need areas. Other proposals include the Health Care Workforce Shortage Initiative, introduced in the FY 2024 budget, which would fund awards used to encourage innovative approaches to health care workforce recruitment and training, with an emphasis on supporting rural and underserved areas.

Similarly, Health Profession Opportunity Grants (HPOG) provide training pathways for low-income people to become nurses, medical assistants, and home health aides. While currently expired, Chairman Heinrich and Senator Wyden introduced the Pathways and Health Careers Act in December 2023 to reauthorize and expand the HPOG program. Reauthorizing the HPOG program would create pathways to these health care careers and provide a mix of support services, including career coaching, job placement, and continuing education. Expanding the HPOG program would make the grants available nationwide, more than doubling the number of states that were previously covered by the program. Ultimately, this could help address shortages in rural and Tribal areas and across the country.

In addition to these efforts, the United States should explore ways to increase the number of residency slots, improve pathways for international medical graduates to get licensed in the United States, allow doctors in the United States on visas to work in health worker shortage areas more easily, and ensure that more states expand Medicaid to shore up local health systems.

Increasing investments that expand rural health care and reduce the shortage of health workers in both rural areas and across the country will help to protect existing rural health services from devastating closures and increase access to health care for all Americans.