Health Care Workforce Shortages Critical in Rural America

Rural households have worse health outcomes than urban households. Access to care is limited due to less insurance coverage, financial hardship and geographical access to care. Highlighted state policies address increasing the health care workforce in rural areas.

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Rural households have worse health outcomes than urban households, even taking into account that rural households are likely to be older.1

  • Rural households have higher rates of mortality, disability and chronic disease.
  • Age-adjusted deaths have slowed in rural and urban areas; however, a gap has opened because the decline in deaths in rural areas is markedly slower than the decline in urban areas.
  • The average annual difference in death rates between metro and nonmetro areas increased from about six additional deaths per 100,000 population in nonmetro areas in 1989 to 82 more deaths per 100,000 population in 2005.
  • Rural areas have less access to health care. Insurance coverage and financial affordability are components, but so is geographical access to care.
  • Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings.2

The U.S. Department of Health and Human Services designates certain areas in states as health professional shortage areas. Rural areas are more likely to be designated as shortage areas than metropolitan areas.

  • More than 6,000 areas in the U.S. have been designated primary care health shortage areas by the department; another 4,300 areas lack sufficient dental health professionals and 3,500 areas are short of mental health (psychiatrists) professionals.
  • Entire counties, as well as certain smaller geographical areas or even individual health facilities, can be designated as health professional shortage areas. Across all states, the department designated 844 counties as primary care shortage areas; 525 counties as dental shortage areas; and 588 counties as mental health shortage areas.
  • More than 60 percent of the shortage areas in each health practice arena are in rural areas. Only 16 percent of all Americans live in nonmetropolitan areas as defined by the U.S. Census Bureau.

The need for more health care professionals to meet target ratios of population care exists in all states, but is especially critical in nonmetropolitan areas.

  • The target ratio for primary care physicians is one for every 2,000 people. To meet this ratio, an additional 16,300 physicians are required, 49 percent of them in rural areas, according to the Department for Health and Human Services.
  • The shortage of professionals to meet target dental health and mental health ratios is more pronounced in nonmetropolitan areas. Federal statistics show that 54 percent of the 9,400 dentists needed to reach a 1-to- 3,000 ratio are required in nonmetropolitan areas. In the mental health field, 71 percent of the required 5,700 additional psychiatrists for a target ratio of 1-to-10,000 are for nonmetropolitan areas.

While the physician shortage is not new, it is expected to increase with the retirement of large numbers of baby boomer doctors at the same time that expanded health insurance coverage will place new demands on the health care system.

  • The Association of American Medical Colleges, in a recent report titled “Help Wanted: More U.S. Doctors,” recommends a 30 percent increase in U.S. medical school enrollment by 2015, which would result in an additional 5,000 new physicians annually.
  • The association supports a concomitant increase in the number of federally supported residency training positions in the nation’s teaching hospitals.
  • The association also recommends the National Health Service Corps give 1,500 additional monetary awards to physicians to encourage more doctors to practice in underserved areas of the country.
  • The picture is not as clear for dentists. Some argue the barriers to dental care access cannot be addressed by merely increasing the number of dentists; indeed, in the 1970s and 1980s there may have been an oversupply of dentists.3

The demand for more physicians translates directly to a demand for more educational investment.

  • The Council on Graduate Medical Education released a report in 2011 addressing the need for more primary care physicians. Their recommendations includes increasing the proportion of primary care physicians from the current 32 percent to 40 percent and requiring medical schools to alter their selection processes and educational environments to support that goal, including more residency training in outpatient settings.
  • A number of studies, including a major study published in the November 2010 issue of the American Journal of Public Health, suggest physicians are more likely to work in underserved areas because of mission-based values—a “sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation”— and self-identification with the area.4
  • Some experts recommend medical schools consider moving from a reliance on score-based criteria for admission to a focus on identifying mission-focused applicants as part of efforts to boost the number of physicians who practice among the underserved.5 Dr. John Stobo, senior vice president for health and health services at the University of California, suggests less emphasis on grades and medical college admission tests (MCat) scores.6

Other potential solutions to the physician and dental shortage include expanding other professionals’ scope of practice and creating wholly new health care professionals.

  • Nurse practitioners are most likely to practice in rural communities. In the U.S., 18 percent of nurse practitioners practice in communities of fewer than 25,000 residents. In states with both a favorable regulatory environment and a large percentage of rural residents, nurse practitioners are significantly more likely to practice in rural settings. Nurse practitioners make up a vital component of rural care, including mental health care. In all states except Alabama and Florida, nurse practitioners can prescribe controlled substances, including prescriptions treating mental illness.7 The five states with the greatest reported percentage of nurse practitioners in rural areas are Vermont (56 percent), South Dakota (50 percent), Wyoming (43 percent), Montana (40 percent), and Maine (39 percent).8
  • The Alaska Dental Health Aide Program enhances access to oral health care by training new types of providers, including dental health aide therapists, to provide culturally appropriate education and routine dental services under the supervision of a dentist to high-risk residents (e.g., children, pregnant women and other high-risk groups) in rural villages. Since 2004, 13 dental therapists have completed the two-year training program and now serve 42 Alaskan villages.9
  • Minnesota’s dental therapists were licensed under the first law of its kind in 2010. Dental therapists are allowed to perform basic services such as simple fillings. In order to be licensed, they must pass a clinical exam and be supervised by a licensed dentist. Dental therapists will serve primarily low-income and uninsured patients, as well as those individuals living in dental shortage areas.10 In Maine and Colorado, dental hygienists can be licensed to practice without the supervision of a dentist in order to increase access to dental care.11
  • Telemedicine also promises to bring more health resources to rural areas. The American Telemedicine Association estimates 200 existing telemedicine networks in the U.S. provide connectivity to more than 3,000 sites.12 Completing the broadband infrastructure is critical for telemedicine to easily connect urban health centers with rural clinics and primary care practices.

The 2010 Affordable Care Act contains several provisions to address health professional shortages.

  • The law provides expanded funding and authority for nurse-managed health care clinics, alternative health care providers to increase access to dental care in rural and underserved areas, community health workers to provide guidance and outreach, primary care extension agents and school based health clinics.
  • The Department of Health and Human Services has awarded $5 million in state workforce planning grants.
  • Funding has been awarded to higher education institutions for 500 new primary care residency slots, 600 new physician assistants and 600 new advanced registered nurse practitioners.


REFERENCES

1 Carol Adaire Jones, Timothy S. Parker and Mary Ahern. “Taking the Pulse of Rural Health Care.” Amber Waves: The Economics of Food, Framing, Natural Resources and Rural America. September 2009. U.S. Department of Agriculture. 

2 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. “Innovations Exchange: Field-Based Outreach Workers Facilitate Access to Health Care and Social Services for Underserved Individuals in Rural Areas.” 

3Albert H. Guay, D.M.D. “Access to dental care: The triad of essential factors in access-to-care programs.” Journal of the American Dental Association. Vol 135, No 6. 779-785. 2004. 

4 “Does Building a Primary Care Workforce Start with Medical School Admissions Committees?” Future of Family Medicine blog. February 14, 2011.

5 Bein, Barbara. “Mission-driven Physicians More Likely to Practice Among Urban Underserved, Study Finds.” AAFP News Now. April 10, 2011. 

6 Mahar, Maggie. “Primary Care and the National Health Service Corps: Finding Physicians “Who Will Go Where No One Else Will Go.” Health Beat Blog. March 3, 2011. 

7 Office of Program Policy Analysis and Government Accountability. Florida Legislature. Research Memorandum. December 31, 2010.

8 “Nurse Practitioners in Primary Care.” American Academy of Nurse Practitioners. 

9 U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. “Innovations Exchange: Dental Health Aide Program Improves Access to Oral Health Care for Rural Alaska Native People.”  

10 Tormey, Kate. “The Health Care Workforce: In Critical Condition?” Firstline Midwest. Council of State Governments. December 2010.

11 Haskell, Meg. “Three bills to benefit independent dental hygienists.” Bangor Daily News. February 13, 2009. 

12 “About Telemedicine.” American Telemedicine Association.