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How to address rural America’s healthcare deficit?

A shortage of doctors is creating ‘medical deserts’ across rural America, leaving millions of people without adequate healthcare, writes Bette Browne

Funding cuts, poor working conditions and tough immigration measures have combined to turn huge swathes of rural America into “medical deserts” where doctors are few and far between and where some have to cover an area one-third the size of Ireland.

This is a problem that affects millions of Americans and it is getting worse. About 20 per cent of the US population – more than 60 million people – live in rural areas, but only 9 per cent of the nation’s doctors practise in rural communities. Indeed, the federal government has designated nearly 80 per cent of rural America as “medically underserved”. The town of Van Horn in south western Texas, for example, has one doctor covering an area of 11,000 square miles.

Data from the Association of American Medical Colleges (AAMC) shows that by 2032, the United States will see a shortage of up to 122,000 doctors, and rural areas will be worst hit by the crisis. “People who are underserved are really going to suffer the most,” according to AAMC Executive Vice President Dr Atul Grover.

Among the reasons he cited for the shortages are population growth and a cap on US congressional funding that covers residency training for doctors. This cap, established by Congress in 1997, has remained unchanged despite significant overall growth in the US population, a large wave of seniors with more complicated health needs, an expansion of health insurance coverage and a shortage of doctors as more retire.

A poll by the Harvard T H Chan School of Public Health, the Robert Wood Johnson Foundation and National Public Radio found that more than four-in-10 rural adults without health insurance (42 per cent) do not get care when they need it, while about one-in-four rural Americans with health insurance (24 per cent) do not get care when they need it.

Chronic diseases are the leading causes of death and disability in America and they affect some populations more than others. People who live in rural areas, for example, are more likely than urban residents to die prematurely from all of the five leading causes of death: Heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke, according to the Centres for Disease Control and Prevention (CDC). Residents of rural areas who have cancer, for example, are diagnosed at later stages of the disease, have less access to clinical trials, worse outcomes, and spend 66 per cent more time travelling to see cancer care providers, the CDC says.

Doctor shortages

As of December 2018, there were more than 7,000 areas in the US with shortages of health professionals, nearly 60 per cent of which were in rural areas. The New England Journal of Medicine, looking at the ‘greying’ of the rural doctor population – more than half are now 50 or older – forecasts that retirement will account for 23 per cent fewer rural doctors by 2030.

The crisis is compounded by the fact that these underserved rural areas are often the very parts of the country that need doctors most. Rural residents have higher rates of conditions, such as obesity and high blood pressure, and they also have higher rates of smoking, which increases the risk of many chronic diseases.

Rural counties also have fewer healthcare workers, specialists, critical care units, emergency facilities, and public transportation. Residents are also more likely to be uninsured and to live farther away from health services.

It is hardly surprising then that numerous studies have demonstrated a significant gap in health outcomes between individuals living in urban areas and those living in rural ones. Yet the very factors that tend to make rural patients sicker are also the same factors that make it difficult to recruit and retain healthcare providers for those areas, according to Prof Amitabh Chandra, Director of Health Policy Research at Harvard University’s John F Kennedy School of Government.

“There are likely a lack of jobs in many of these places, as well as lower quality schools and housing. Doctors know better than anyone the importance of good healthcare to a thriving community,” Prof Chandra points out. “Will they be comfortable moving to an area and raising a family in a place where you can’t get great hospital care – or perhaps any hospital care at all within a hundred miles?”

Prof Amitabh Chandra

Hospital closures

The situation is made worse by the fact that rural hospitals are also in decline and the number closing their doors has been growing in recent years. Over 100 rural hospitals have closed in the last decade and hundreds more are facing closure. The North Carolina Rural Health Research Programme says that 19 rural hospitals closed in 2019, up from 15 closures in 2018, continuing a steady double-digit trend in closures since 2013.

Indeed, despite a booming US economy, 2019 was the worst year for hospital closings since at least 2005. Since that year, the North Carolina researchers tracked 162 hospital closings, with 60 per cent of the closures occurring in southern states. In many of these states, poverty rates are higher, people are generally less healthy and less likely to be able to afford private health insurance and pay their hospital bills, leaving rural hospitals and hospitals in low-income areas with mounting costs.

Most hospitals have closed because of financial problems. About 38 per cent of rural hospitals are unprofitable. In 2016, for example, 1,375 acute care hospitals out of 4,471 urban and rural acute care hospitals (31 per cent) were unprofitable, including 847 rural hospitals (versus 528 unprofitable urban hospitals).

University of Minnesota research shows that between 2004 and 2014, a total of 179 rural counties lost all hospital-based obstetrics services. Another disturbing statistic that underscores the problem is that over the last 15 years, the difference in mortality between rural and urban areas has tripled – from a 6 per cent to an 18 per cent difference in 2015.

The National Rural Health Association, an advocacy body for rural healthcare issues says “continued cuts to rural providers are creating a hospital closure crisis in rural America, jeopardising millions of rural patients’ access to medical care and devastating the already fragile rural economy”.

Currently one-in-three rural hospitals is in financial risk. At the current rate of closure, the association says, 25 per cent of all rural hospitals will close within less than a decade.

“Once a hospital closes, many of the health professionals employed by the hospital, including physicians, nurses, and pharmacists move from the community,” according to the Association.

“Medical deserts are appearing across rural America, leaving many of our nation’s most vulnerable populations without timely access to care.”

Incentives

Different methods of tackling the crisis are being explored. While the most straightforward approach may seem to be to offer more financially lucrative deals to doctors to encourage them to practise in rural areas, Prof Chandra of Harvard University says simply throwing money at the problem is not the answer.

“The amount of money that you’d need to try and make up for what these doctors could make in the city would be cost-prohibitive,” he says. “We aren’t talking about the state or other agencies adding 5 per cent in extra wages, but more like 40 per cent, 50 per cent, maybe even 60 per cent to make up the difference. Instead of focusing on salary, we need to think more creatively about how we can make rural America more attractive to doctors and their families.”

Most physicians tend to practise where they are trained and the majority of medical schools and residencies are affiliated with hospitals in urban areas. Rural salaries are also lower, and young doctors often factor large loan repayments into decisions about how and where to practise. Such loans can be substantial. The Association of American Medical Colleges found that among the three-quarters of students in the class of 2018 who needed loans to pay for medical school, the median debt was $195,000 (€177,000).

With that in mind, one suggestion to address the issue is that new doctors could have their medical school loans paid for if they agreed to go into primary care in an underserved rural area for a given number of years.

South Dakota has a recruitment assistance programme that offers an incentive payment of $231,384 (€200,000) for qualifying physicians or dentists who make a three-year commitment to one of the state’s community clinics and more than $66,000 (€60,000) for qualifying physician assistants, nurse practitioners, or nurse midwives. Alabama, which ranks in the bottom five US states for healthcare, offers scholarships and a rural physician tax credit.

Democratic Presidential hopeful Joe Biden, seeking to take on President Donald Trump in the November election, has made improving rural healthcare a key piece of his strategy for boosting rural America. He says his top goals are to keep rural hospitals open and to reduce out-of-pocket expenses paid by rural Americans.

He is not the first to call for investment into rural healthcare.

‘Scope of practice’ legislation

Several state and federal programmes and legislation are also aimed at improving the situation. In recent years, more and more states have enacted ‘scope of practice’ legislation, which has broadened the ability of non-physician practitioners to provide care for Americans. Such moves are also helping to address the shortage of doctors in rural areas.

More than 40 states introduced scope of practice legislation during the 2019 legislative sessions. The National Conference of State Legislatures’ Scope of Practice Policy website has tracked a total of 177 bills. Fifty-four bills from 30 states were enacted into law related to behavioural health providers, physician assistants, nurse practitioners and oral health providers.

Behavioural health providers saw 17 bills address certification and licensure standards, supervisory and prescribing authority, and reimbursement requirements. Arkansas passed at least three bills relating to peer support specialist certification and practice and prescribing authority for nurse practitioners. Individuals with prior drug-related offences can now work with people receiving substance abuse treatment as peer support specialists.

Twelve states enacted legislation addressing licensure and reciprocity for addiction counselors. The states of Minnesota, North Dakota and Washington each established a reciprocity programme for addiction counselors applying for certification in their states.

Sixteen bills nationwide addressed the relationship between a physician assistant and a physician, and authorised additional procedures that could be performed by the physician assistant. California, for example, now allows physician assistants to work in collaboration with a physician instead of under delegation and allows for development of the practice agreement in collaboration with a physician. Missouri allows for collaboration between a physician assistant and a physician, and the physician also no longer needs to practise at the same facility as the physician assistant. Nurse practitioners saw six bills address prescribing ability.

The bipartisan Training the Next Generation of Primary Care Doctors would authorise nearly $650 million (€588 million) over five years to train medical residents in low-income, underserved rural and urban neighbourhoods.

The American Academy of Family Physicians found that physicians, who practise family medicine, have a rural background and take part in rotations in rural areas while in medical school are more likely to choose to practise in rural areas. That was confirmed in a study published in the Journal of Rural Health showing that an eight-week rural rotation was enough to give urban students positive opinions about living and working in rural communities.

The Quillen College of Medicine at East Tennessee State University is among a small group of medical schools in the US with programmes aimed at bolstering the number of primary care doctors in rural communities. The schools send students to live in small towns and train with rural doctors. Like Quillen College, some also organise outings and cultural experiences to try to encourage students to continue living there after they graduate. Schools have taken students to a ranch to brand cattle, brought in local story tellers and offered local delicacies to show students what rural life can offer.

The federal government has also allocated $20 million (€18 million) in grants to help create 27 rural residency programmes where new doctors go for practical training before they can be fully licensed. A bipartisan bill that aims to encourage more medical professionals to work in small towns has also been introduced in the US congress by Illinois Senator Dick Durbin. This legislation would allow eligible doctors to participate in a sliding scale loan repayment programme that would incentivise them to work in the places with the most severe shortages of doctors. 

Senator Dick Durbin

The Rural America Health Corps Act would create a new programme that improves the existing National Health Service Corps (NHSC) by providing new dedicated student loan forgiveness funding for healthcare providers who agree to work in rural communities. Twenty per cent of Americans live in rural communities, yet only 11 per cent of physicians practise in such communities. Across the state of Illinois, with a population of some 12 million, about 3.3 million people live in communities with shortages of doctors, five million people live in communities with shortages of mental health professionals, and 2.3 million people live in communities with shortages of dentists.

“Patients across rural Illinois face challenges accessing the healthcare they need because of serious workforce shortages, with too few medical providers and long distances between them,” Senator Durbin said when introducing the Rural America Health Corps Act. “Our bipartisan bill provides new funding and support for rural communities by expanding loan forgiveness programmes so we can attract and retain more doctors, dentists, behavioural health specialists, and nurses.”

The current National Health Service Corps programme provides up to $50,000  (€45,000) annually to repay student loans for primary care doctors, dentists, behavioural health clinicians, nurse practitioners, and physician assistants for two years of service in a “health professional shortage area”. Eligible locations include urban and rural hospitals and community health clinics with a shortage of providers. It provides approximately 3,100 new loan forgiveness awards each year – but only 30 per cent of participants in the National Health Service Corps programme serve in rural communities.

The Rural America Health Corps Act would create a new $25 million (€23 million) programme that would bolster the existing rural placements and would provide funding for up to five years – an increase from the current two-year forgiveness period – for doctors, dentists, behavioural health specialists, and nurse practitioners, which would help recruitment and retention efforts.    

Telemedicine is also helping, as are physician assistants, while a new bill to improve broadband connectivity in areas with limited access to care has been introduced in the Senate. The Data Mapping to Save Moms’ Lives Act will allow for the mapping of areas that lack maternal care and access to the internet, with the goal of improving tele-health technology infrastructure in areas with critical maternal healthcare needs.

Global problem

Many of these problems in the US will sound familiar to rural doctors in some parts of Ireland. Hundreds of GPs are due to retire around the country in the coming years and it is feared that few young doctors will be prepared to work in more remote rural areas because of the greater workload and reduced resources. Instead, young graduates tend to be more attracted by working conditions and training opportunities abroad, or they prefer to live and work in large urban areas.

Indeed, the World Health Organisation (WHO) sees the issue as an important global challenge that affects rural and low-population areas in many developed and developing countries worldwide.

Many developed nations, it says, have an aging population, which in countries like Japan and Germany, is putting pressure on their healthcare systems and services for both rural and urban populations. “Ease of access to healthcare in rural communities is an important global challenge that must be tackled and is one of the priorities of the WHO.”

A study from a consortium of five Japanese universities has shown that different university programmes to promote the equal geographic distribution of doctors increases the number of graduates practising in rural areas in Japan. Graduates from these programmes were on average 24 per cent more likely to work in non-metropolitan areas than those not involved in these programmes.

Japan has admissions programmes integrated in each university with a medical school, which either obliges or encourages medical school graduates to practise in rural areas. There are three types of programmes: The regional quota programme where a certain number of the incoming high-school students in a medical course must be from a local region, the scholarship programme where the medical students benefit from a scholarship for six years in exchange for practising in designated areas after graduation, and a combined quota and scholarship programme.

Immigrant doctors

Immigrant doctors could also play a critical role in filling physician shortages in rural communities across the United States. Yet they often face tough immigration and licensing barriers that prevent them from serving in these communities, according to the Centre for American Progress, a non-partisan policy institute.

“It’s also clear that current state and federal regulatory frameworks pose barriers for immigrant doctors who want to work in rural areas,” says Silva Mathema, the institute’s senior policy analyst of immigration policy. “The United States needs reforms at all levels of government to harness the talents of immigrant doctors to help minimise physician shortages and ensure that patients in rural communities get the care they need.”

Immigrants make up a sizeable proportion of the US healthcare workforce. According to data from the Migration Policy Institute, 30 per cent of all active physicians and surgeons are immigrants, but many are being hit by tough immigration measurers introduced by the Trump administration. Iran and Syria, for example, two of the countries whose citizens are now generally banned or face tight restrictions entering the US, are the sixth and 10th largest contributors of immigrant doctors.

Data from the Association of American Medical Colleges shows that foreign-trained doctors do a disproportionate amount of the work in certain areas. They make up more than 50 per cent of geriatric medicine doctors, almost half of nephrologists, nearly 40 per cent of internal medicine doctors, and nearly a quarter of family medicine physicians.

Compared with US-trained physicians, immigrant doctors are also more likely to practise in rural areas. Many enter the US on visas that allow them to stay if they work in an underserved area for three years after residency. And the patients they treat in these rural areas are getting high quality care.

A 2017 study in the BMJ concluded that patients treated by international graduates had lower mortality than patients cared for by US graduates. The study suggested that this may be because such graduates probably represent “some of the best physicians in their country of origin” and had to overcome intense competition and years of training to finally practise in the United States.

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