Authored by: Charles Snajdr
You’re at home eating dinner with your family. Suddenly, you get shortness of breath and start to feel intense chest pain – you’re having a heart attack. Your grandson quickly calls 911 and tells you an ambulance is on the way. Unfortunately, you live in a rural town and the next closest emergency room is an hour away. Your chances of survival are slim.
This dark scenario is a real concern for many rural Americans. Close to 60 million people live in rural areas nationwide [1]. These areas are found to have just five primary care physicians per 10,000 residents, while urban areas have eight [2]. This demonstrates a two-sided problem in rural healthcare: patients have almost half as many doctors available, their doctors have many more patients to see. To make matters worse, 105 rural hospitals have closed since 2015, and currently, more than 700 are at risk of closing. US rural health systems could see almost a third of their hospitals shut down [3].
There is a clear issue with the accessibility of healthcare providers in rural settings. But how do we fix this? How can we increase the number of high-quality medical care outlets?
Before answering these questions, we must first understand rural healthcare and acknowledge how its patients differ from urban populations. The most notable difference is geography and community size. In urban areas, there often exist multiple health systems, whose facilities branch out even further to surrounding suburban areas. However, in a small town of 1,000 residents, there may only be one primary care physician (PCP), and a specialist could be over an hour drive away – in a small to medium-sized city with already slim provider choices.
The patient demographics of rural areas also add to the complexity of providing adequate healthcare. According to US census data, rural populations tend to be older [4]. Older patients have greater representation for various chronic diseases – regardless of geographic location. This means that these patients largely require more medical care, which puts greater strain on rural health systems that already have very few providers. Additionally, addiction and substance abuse are an issue for many rural areas [5], and rural doctors must navigate this while treating affected patients.
As healthcare advances, it is important that care in our rural communities does not lag. In 2023, the Biden Administration proposed to improve rural healthcare by allocating $30 million to rural hospitals on the verge of closing. The plan also incorporated $10 million in the 2024 budget to help expand behavioral health care in rural areas [6].
But in addition to aiding existing rural health providers, policies for attracting new providers to rural areas are needed. Especially because geographic dispersion and provider shortage are two of the most significant barriers to access in rural healthcare [7].
Such policy initiatives should be developed with a rural-patient centered approach. The best way to do this is to help rural residents become physicians, rather than only incentivizing urban or suburban providers to relocate.
An effective plan would have two parts. The first action involves supplementing existing federal aid to rural and Critical Access Hospitals (CAHs) with additional funding that should be specifically allocated to developing residency programs. This would be significantly effective in programs for primary care training. Data shows that medical residents trained for primary care in rural areas are much more likely to practice primary care in rural locations upon completion of residency [8]. Not only would this improve provider access, but by opening more residency spots, it would also help the “bottleneck” that exists in the residency match program in the U.S. [9].
The second part of this agenda should address structural barriers to entry into medical professions that exist for rural individuals. Medical school is expensive, and medical debt upon graduation is a common burden for physicians across the board. As such, it presents a steep cost hurdle that likely deters rural students from pursuing careers in medicine. Additionally, matriculation to medical school requires completion of a 4-year bachelor’s degree from an accredited college. Access to college education is an issue on its own in rural populations, but policies to increase access to medical school should also support rural students in graduating from 4-year colleges.
You’re probably thinking, “this sounds great, but wouldn’t these efforts be expensive?” This is a valid concern, but there is an opportunity for a positive benefit-to-cost ratio with this approach, especially in the long run. By funding efforts to increase the accessibility of medical training in rural areas, we can directly raise the number of PCPs. With PCPs available to patients, they can quickly diagnose and prevent the development of chronic conditions much earlier. These are drivers of high-cost healthcare spending later in patients’ lives. As there are 26 million rural Medicare and Medicaid enrollees [10], this would bring significant savings on government healthcare spending down the line.
Rural healthcare faces significant challenges. Investing in approaches that aim to build a foundation of rural providers can offer a sustainable solution. Supporting the establishment of local residency programs and assisting rural students in becoming physicians are policies that would yield tangible results. These efforts also have the potential to improve health outcomes and reduce long-term costs. Overall, shortening the health equity gap faced by rural patients.
Works Cited
America Counts Staff. (2018, September 18). What is Rural America? The United States Census Bureau. https://www.census.gov/library/stories/2017/08/rural-america.html
Availability of healthcare providers in rural areas lags that of urban areas. (n.d.). Www.ers.usda.gov. https://www.ers.usda.gov/data-products/chart-gallery/gallery/chart-detail/?chartId=106208
Center for Healthcare Quality and Payment Reform. (n.d.). The Crisis in Rural Health Care. Ruralhospitals.chqpr.org. https://ruralhospitals.chqpr.org/
US Census Bureau. (2017, May 25). A Glance at the Age Structure and Labor Force Participation of Rural America. The United States Census Bureau. https://www.census.gov/newsroom/blogs/random-samplings/2016/12/a_glance_at_the_age.html
Rural Health Information Hub. (2024, August 2). Substance Use and Misuse in Rural Areas Introduction - Rural Health Information Hub. Www.ruralhealthinfo.org. https://www.ruralhealthinfo.org/topics/substance-use
Assistant Secretary for Public Affairs (ASPA). (2023, November 3). The Biden-Harris Administration is taking actions to improve the health of rural communities and help rural health care providers stay open. Www.hhs.gov. https://www.hhs.gov/about/news/2023/11/03/department-health-human-services-actions-support-rural-america-rural-health-care-providers.html
Maganty, A., Byrnes, M. E., Hamm, M., Wasilko, R., Sabik, L. M., Davies, B. J., & Jacobs, B. L. (2023). Barriers to rural health care from the provider perspective. Rural and remote health, 23(2), 7769. https://doi.org/10.22605/RRH7769
Goodfellow, A., Ulloa, J. G., Dowling, P. T., Talamantes, E., Chheda, S., Bone, C., & Moreno, G. (2016). Predictors of Primary Care Physician Practice Location in Underserved Urban and Rural Areas in the United States: A Systematic Literature Review. Academic Medicine : Journal of the Association of American Medical Colleges, 91(9), 1313–1321. https://doi.org/10.1097/ACM.0000000000001203
Orr, R. (2021, September 20). Unmatched: Repairing the U.S. Medical Residency Pipeline. Niskanen Center. https://www.niskanencenter.org/unmatched-repairing-the-u-s-medical-residency-pipeline/
Office, A. P. (2024, November). Biden-Harris Administration Releases New Report that Shows Gains in Health Care Coverage for Rural Americans. HHS.gov. https://www.hhs.gov/about/news/2024/11/01/biden-harris-administration-releases-new-report-shows-gains-health-care-coverage-rural-americans.html
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