This report contains a correction.
Introduction and summary
Rural communities throughout the United States lack access to health care. While only 14 percent of Americans—almost 46 million people—live in rural areas, rural communities represent nearly two-thirds of primary care health professional shortage areas (HPSAs) in the country.1 This amounts to more than 4,100 primary care HPSAs in rural areas. A 2018 report by Pew Research Center found that the average time to drive to a hospital in rural communities was 17 minutes, nearly 65 percent longer than the average drive in urban communities.2 The coronavirus crisis highlighted this gap in access: These long-standing disparities have resulted in clear health differences between more rural and more urban areas, increasing rural residents’ risk of COVID-19 and severe illness from it.3
While only 14 percent of Americans—almost 46 million people—live in rural areas, rural communities represent nearly two-thirds of primary care health professional shortage areas.
The Kaiser Family Foundation estimates that an additional 14,858 health care providers are needed to eliminate this shortage across the country.4 A 2021 survey found that the hospital turnover rate—the aggregate rate of employee turnover for a hospital—increased to 19.5 percent in 2020, and 16 percent fewer hospitals expected an increase in their labor force in 2020 than in 2019.5 Ensuring that the supply of health care providers outpaces the turnover rate—and that supply is distributed to areas with shortages rather than to areas with existing provider surpluses—is critical to ensuring the health of rural communities.
While some actions to address the shortage of health care providers must be taken by the federal government, such as increasing the number of medical school residency slots,6 states have several policy options to increase health care access and provider supply in rural communities. These include programs to address the financial barriers to entering and remaining in the medical profession; changes to scopes of practice for nonphysician providers; and policies to promote newer methods of receiving care. These reforms can help ensure that a person in need of medical care can receive care quickly, that medical professionals are drawn to areas in need, and that the availability of care is not dependent upon where families live. As the United States continues to recover from the COVID-19 pandemic, ensuring that all Americans have access to care is essential to building an equitable recovery.
The Kaiser Family Foundation estimates that an additional 14,858 health care providers are needed to eliminate this shortage across the country.
Financial barriers to physician practice
Some of the most significant barriers to establishing rural health care practice are financial in nature. As explored below, these obstacles include educational affordability and its effect on the development and placement of the health care provider supply as well as the steep cost of medical malpractice insurance and its impact on retaining a health care provider workforce.
The high cost of medical school limits the number of students who apply and attend.7 High levels of student loan debt can lead physicians to pursue high salaries, which can incentivize practicing in populous urban areas over less populous rural settings.8 Additionally, as the COVID-19 pandemic led many states to temporarily prohibit elective procedures, rural settings are at even greater risk of long-term financial unsustainability.9 States can take two policy approaches to help make medical school more affordable and to encourage providers to practice in rural communities after graduation: loan repayment and loan issuance and assistance.
Loan repayment programs
Loan repayment programs are initiatives under which a state repays or facilitates the repayment of student loans for qualifying health care providers. The National Health Service Corps’ (NHSC) State Loan Repayment Program (SLRP), for example, is a partnership between states, territories, and the NHSC to promote physician practice in rural communities.* Under the program, clinicians specializing in primary care, dental care, and behavioral or mental health care can receive up to $50,000 in federally funded loan repayments. While the NHSC SLRP has had a positive effect overall, there are several aspects of the program that reduce its efficacy at promoting rural practice.
Current loan repayment programs are insufficient
Average medical school graduate debt
Average dental school graduate debt
Maximum loan repayment through federal government
Foremost is the reality that the repayment amounts, while substantial, comprise a relatively small amount of the total debt accrued by the average doctor during medical or dental school. The most recent data from the Association of American Medical Colleges estimate the average medical school graduate debt in 2021 at $203,062.10 Similarly, the American Dental Education Association estimates the average dental school graduate debt in 2020 at $304,824.11 Repayments of $50,000 represent less than 25 percent and 20 percent of medical and dental graduates’ average debts, respectively. Additionally, not all states provide the matching funds from state dollars. For example, Kentucky requires that applicants secure a private sponsor for the nonfederal portion of the program.12 Supplementing federal funds with state funds to increase the proportion of debt forgiven is a simple method by which states can incentivize physicians to practice in rural settings. The American Rescue Plan Act presents an easy opportunity for states to do so: The law included $100 million in grants to states to make loan repayment awards for medical and dental school graduates, in addition to the $800 million appropriated to the NHSC to create new loan repayment agreements.13 Congress should consider making these investments permanent, but states should also take advantage of the temporary grants while they exist.
In addition to the issue of low funding, onerous state eligibility requirements for the NHSC SLRP can also reduce the program’s efficacy. The federal standards for the program allow providers to practice in a wide range of settings, including in federally qualified health centers (FQHCs) and FQHC look-alikes, rural health clinics, Indian Health Service clinics, and private practice.14 States should ensure that their participation requirements align with the full breadth of the federal program in order to maximize participation.
Loan issuance and assistance programs
In addition to loan repayment programs, states can also operate or supplement existing loan issuance programs. For example, the Rural Illinois Medical Student Assistance Program (RIMSAP) offers student loans to medical students who complete a portion of their education in rural settings.15 The program is similar to the NHSC SLRP in that they both work to address the high cost of medical school through government funding. The primary differences between the two programs are the funding source and the stage of education at which students receive the funding: RIMSAP is funded through private sources, while the NHSC SLRP is funded through the federal government; RIMSAP funds are provided upfront to students during their education, while the NHSC SLRP is provided after graduation. These RIMSAP loans are provided at a 4 percent interest rate by the Illinois Farm Bureau, the Illinois State Medical Society, and two University of Illinois rural medical programs and are capped at $50,000 per student and $6,250 per year.16 The purpose of the program is to “provide doctors in rural communities in Illinois.”
RIMSAP influences where medical students choose to pursue their education, but the program faces similar barriers to efficacy as the NHSC SLRP. The Association of American Medical Colleges reports that the average cost of attendance—tuition and fees—for a first-year medical student at an in-state public medical school in 2021 was $36,365.17 The maximum loan amount of $12,500 per student per year through RIMSAP means that the program only covers around one-third of the cost of attendance for medical students. Additionally, the program is largely limited to physicians: Dentists are not eligible at all, and only five $4,000 scholarships are awarded to nurse practitioners.18 While nurse practitioners tend to have lower student debt than physicians—between $40,000 and $54,999, on average19—the level of funding provided to them is significantly lower than the difference in debt.
Expanding the eligibility and funding for loan assistance programs can help ensure that the supply of rural providers is not adversely affected by students’ financial strains.
Expanding the eligibility and funding for loan assistance programs can help ensure that the supply of rural providers is not adversely affected by students’ financial strains. One benefit to expanding student assistance programs over loan repayment programs is the potential for lower interest rates. The interest rate for federal medical school loans is 6.08 percent, which is significantly higher than the 4 percent interest rate for RIMSAP loans.20 This difference in interest rates may perpetuate the perception of medical school as unaffordable, particularly to students who have historically lacked access to higher education, such as students of color and students from lower-income backgrounds. Additionally, providing students with funds upfront, rather than after graduation, in the form of lower-interest loans helps decrease overall costs by reducing interest accrued. However, without changes to the terms of the loans, this may reduce the programs’ efficacy at influencing where physicians eventually choose to practice.
In addition to education affordability, the high cost of medical malpractice coverage presents another financial barrier even after providers enter the workforce. Medical malpractice insurance protects physicians and other providers from liability if services result in patient injury or death.21 Only seven states—Colorado, Connecticut, Kansas, Massachusetts, New Jersey, Rhode Island, and Wisconsin—require physicians to maintain a minimum level of medical malpractice insurance coverage.22 Another six states—Indiana, Nebraska, New Mexico, New York, Pennsylvania, and Wyoming—require physicians to have a minimum level of coverage in order to qualify for certain state programs such as patient compensation funds.23 While most states do not require coverage, most practicing doctors maintain malpractice insurance due to the possibility of being responsible for a large payment in the event of a medical error.24
Implementing a state-run program to help reduce the cost of medical malpractice insurance for providers can help promote rural health care practice.
Implementing a state-run program to help reduce the cost of medical malpractice insurance for providers can help promote rural health care practice. For example, New York state provides additional coverage to physicians with hospital privileges who maintain primary coverage at a specified, minimum level.25 New York’s “excess coverage” program significantly boosts physicians’ amount of coverage, nearly doubling the individual claim coverage amount and increasing the aggregate claim coverage amount by more than 75 percent. Indiana and Pennsylvania both operate similar programs with differing minimum coverage and excess coverage amounts.26
Alternatively, states could directly subsidize the cost of medical malpractice insurance premiums. While both types of programs—reducing the cost of the insurance or directly subsidizing the cost of premiums—would improve the affordability of medical malpractice coverage for physicians in the state, the programs are not identical in their effect or cost. Directly subsidizing premium costs would likely be more effective at improving affordability, but it would also come with a higher price tag for the state. Providing excess coverage would only supplement providers who can already afford the minimum level of coverage, but it would have a lesser budgetary impact on the state as a result.
However, either option would significantly help to reduce rural provider loss in the state. A 2004 Journal of the American Medical Association study of rural physicians in Florida found that “difficulty finding or paying for PLI [medical malpractice insurance] was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years.”27 By implementing a similar program to that of New York—based on state-specific coverage levels and costs or direct subsidies for malpractice insurance premiums—states can eliminate or reduce this barrier to rural practice and promote the flow of rural providers. Additionally, such a program can help reduce opposition from physicians to the scope-of-practice reforms mentioned in the next section of this report, which physicians may view as a threat to their existing practices.
Another option that states could pursue is to establish standards for how and when medical malpractice suits can be brought against providers. For example, a 2013 CAP issue brief proposed creating a “safe harbor” for providers.28 Under this proposal, providers would be protected from malpractice suits if they document adherence to evidence-based standards and use decision-support systems that incorporate guidelines to assist with diagnosis and treatment options.29 This approach would help reduce spending on wasteful “defensive medicine”—unnecessary testing, procedures, or other consultations to avoid accusations of negligence. Doing so would improve the quality of care patients receive and reduce the amount of lawsuits brought against providers, eventually lowering premiums for medical malpractice coverage by reducing risk.30 States should ensure that the guidelines and standards used to inform these safe harbor protections are based on a systematic review of existing evidence and ensure that medically complex patients, such as chronically ill and disabled patients, continue to receive necessary testing and care.
Physicians and dentists are important health care providers, but they are not the only providers from whom patients can receive care. As the COVID-19 pandemic demonstrated, nonphysician providers such as nurses play a critical role in the health care system. Nurses helped lead the public health response to the pandemic,31 and expanding their ability to practice is an essential way to promote health care access. Unfortunately, the aging U.S. population and burnout from multiple years of the pandemic has led to a severe nursing shortage.32
This section discusses two potential changes to scopes of practice for advanced practice registered nurses (APRNs) and physician assistants (PAs), as well as the establishment of a scope of practice for dental health aide therapists (DHATs). It also lays out evidence demonstrating the high-quality care that these providers deliver and their ability to help fill provider shortages, particularly in rural areas.
Expanding the scope of practice for PAs and APRNs
Nonphysician providers represent an important portion of health care provider supply, and state policies should ensure that these providers are being incentivized both to practice within the state and work in rural communities in particular. Scope-of-practice regulations vary significantly by state, which reduces states’ abilities to promote these nonphysician providers. Two of the most significant barriers to practice for APRNs and PAs include practice independence and prescriptive authority. Only 24 states and Washington, D.C., allow APRNs to practice independently, and while most states allow APRNS to prescribe medications, the types of drugs they can prescribe differ widely across states. The level of physician oversight required for APRNs to prescribe medications varies from state to state as well.33 Similarly, nearly every state requires physicians to supervise Pas; only a few, such as Alaska and Illinois, describe the relationship between Pas and physicians as collaborative rather than supervisory, and no state allows for fully independent practice by Pas.34 As with APRNs, most states allow Pas to prescribe medications, but this prescriptive authority can be subject to additional limitations. For example, while Alabama allows Pas to prescribe Schedule III to Schedule V medications—categorized as drugs with a lower potential for abuse—supervising physicians are able to restrict this authority, even if the Pas meet the statutory and educational requirements.35
Many states temporarily waived scope-of-practice regulations during the pandemic: Pennsylvania, Tennessee, and Wisconsin waived supervision requirements for nurse practitioners, and California relaxed the same requirement for APRNs.36 Some states have made these temporary waivers permanent, potentially expanding access to care in underserved regions. Arkansas and Massachusetts both passed legislation in 2021 expanding the scope of practice for APRNs, with Arkansas permanently allowing for independent practice for some nurses.37
The pre-pandemic literature shows that expanding scope of practice for nonphysician providers does not diminish quality of care and can improve access to care.
While the impact of these waivers has not yet been systematically evaluated, the pre-pandemic literature shows that expanding scope of practice for nonphysician providers does not diminish quality of care and can improve access to care. A 2017 study in Medical Care examined nine quality, service utilization, and referral pattern measures based on data from five years’ worth of appointments. The researchers found no statistical difference for 7 of the 9 outcomes examined and found that nurse practitioner patients and PA patients were more likely to receive smoking cessation counseling and health education counseling, respectively, than primary care physician patients.38 Furthermore, a 2018 study examined the effect of scope-of-practice regulations on rural health outcomes and found no statistical difference in outcomes when states expanded scopes of practice for nurse practitioners.39
Establishing further adjustments to scope of practice and making temporary adjustments permanent can be effective tools to grow a state’s nonphysician health care workforce. Evidence suggests that nonphysician providers are less likely to move from a state where they are granted prescriptive authority to a state where they are not.40 A 2013 study found that restrictive scope-of-practice regulations reduce APRN numbers by around 10 per 100,000 people and reduce the growth rate of people who enter the profession by approximately 25 percent.41 Another study, conducted in 2016, found that states that allow independent practice have 5.4 more APRNs per 100,000 people than states with blanket restrictions on APRN practice—and that states with collaborative practice requirements have 4.1 more APRNs per 100,000 people.42 By removing barriers to practice, including by making pandemic-era changes permanent, policymakers can ensure that regulations are not inadvertently disincentivizing providers from practicing in their state.
Establishing a scope of practice for DHATs
In addition to expanding access to primary care through APRN and PA regulations, states can also utilize scope-of-practice regulations to improve dental care access in rural communities. As with medical care, rural communities have less access to dental care than their urban counterparts. The 2019 edition of the Centers for Disease Control and Prevention’s annual report on the health status of the United States found that nonelderly adults living outside metropolitan statistical areas (MSAs) were more than 9 percentage points less likely than MSA residents to have visited the dentist in the past year.43 This disparity is partially driven by a lack of provider supply, as rural communities typically have fewer dentists per person than urban areas.44
DHATs are to the dentistry profession what Pas are to the medical field. Like Pas, DHATs have a more limited scope of practice and are often required to practice collaboratively or in a supervisory relationship with dentists.45 Alaska has used such providers since 2004, largely to serve its Alaska Native communities.46 Alaska allows DHATs who have completed two years of dental education to provide various basic services, such as sealants and extractions, without requiring the advanced training that dentists receive.47 This practice allows for easier entry into the dental profession and helps increase the supply of providers who can offer simple, preventive services that can reduce the need for more complicated, reactive services. Other states, such as Washington and Minnesota, have allowed DHATs to practice in recent years.48 Minnesota’s law is particularly targeted toward expanding rural dental access: DHATs are allowed to practice only in settings that serve low-income, uninsured, and underserved patients, or within a dental HPSA.49
Research finds Alaska Native children receiving DHAT services see benefits
Fewer tooth extractions
Higher rates of preventive dental care
Studies routinely find that DHATs deliver care of a similar, if not higher, quality than that provided by dentists,50 and a 2008 study of Alaska’s program concluded that the use of DHATs could represent “a viable long-term solution” to poor oral health care access among Alaska Native people.51 Another more recent study of the program came to a similar conclusion: Researchers at the University of Washington found that Alaska Native children receiving DHAT services had 5.4 percent fewer tooth extractions and 9.3 percent higher rates of preventive dental care than those not receiving DHAT services.52 Studies examining other populations support this conclusion as well: A review of nearly two dozen studies in other nations on the quality of care provided by DHATs overwhelmingly concludes that DHATs provide high-quality, “clinically competent” care.53 For example, an examination of restorations by DHATs in Melbourne, Australia, found that only 5.4 percent of restorations required retreatment six months later.54 The authors of the study specifically highlighted the value of DHATs “in rural areas where workforce shortages are most acute.”55
It is important to recognize the level of opposition this reform would face from the dental profession. The American Dental Association opposes allowing DHATs to practice independently, on the basis that it represents an inferior level of care, and state dental societies would likely work to impose regulations similar to the supervisory requirements that APRNs and PAs face in other states as the bill moves through the legislative process.56 One option to address this opposition is to operate the reform as a pilot project, similar to the approach taken in Alaska. Additionally, by limiting the implementation of DHAT expansion solely to a given state’s medically underserved areas in which dentists are not currently operating—as Minnesota did—the effects on dentists’ practices would be less considerable than if the scope-of-practice expansion were implemented statewide. Emphasizing the reality that dentists and DHATs largely serve different patient populations can also help mitigate reticence from the dental profession—or at least the influence of such opposition on state legislators.57
Innovative care modalities
Another opportunity to improve the rural health care provider supply is expanding nontraditional sources of care. For many rural communities, expanding practice through traditional in-office care is not a feasible solution. The low population density of these communities makes in-office practice unsustainable, as practices may not see enough patients to cover their costs. Alternative modalities such as telemedicine and mobile clinics present two opportunities to increase medical access in rural health care deserts.
Telemedicine is the use of electronic information and telecommunications technologies to support long-distance clinical health care and patient education.58 It can be used to improve access to providers for patients who would otherwise have to travel long distances to receive such care, and it can help reduce the number of patient transfers from smaller, rural hospitals.59 The federal government has taken steps to expand telemedicine access during the pandemic: The Centers for Medicare and Medicaid Services amended its telemedicine policy to ensure that it covered telehealth claims for traditional Medicare beneficiaries, resulting in significant increases in telemedicine visits, and the U.S. Department of Health and Human Services issued regulations allowing additional clinics to serve as distant telehealth sites.60 As with many of the reforms discussed in this report, one of the largest barriers to the widespread adoption of rural telemedicine is cost.
While many states have made policy changes in response to the coronavirus crisis, full parity has not been achieved. Every state and Washington, D.C., require Medicaid to cover live video, but only 22 states require coverage of store and forwarding, another common telemedicine method in which providers send patient clinical information, such as X-rays, MRIs, and photos, electronically to another site for evaluation.61 This distinction is important, especially for low-income rural residents who might lack access to internet speeds needed to make effective use of live video telemedicine.62 Similarly, a recent study found that rural Medicare beneficiaries were less likely than urban beneficiaries to use telemedicine during the COVID-19 pandemic, highlighting the need for policies to cover a variety of telemedicine formats.63
In addition to Medicaid coverage, 43 states and Washington, D.C., have telemedicine coverage requirements for private health insurers, but less than half of those states mandate equal reimbursement for telemedicine services, known as telemedicine parity.64 Telemedicine parity is especially important for ensuring rural health care access via telemedicine. While mandating coverage is a useful start, without parity, such coverage may allow for unequal reimbursement for similar services according to the method through which those services were delivered. As a result, this disincentivizes providers from offering telemedicine.
States should enact telemedicine parity regulations for both Medicaid and private insurers in order to lessen the financial barriers to broader use of telemedicine.
Many states with large rural populations and high levels of rural HPSAs—such as Alabama and Idaho—have not adopted these equal coverage requirements, which represent a significant opportunity to expand health care access. States should enact telemedicine parity regulations for both Medicaid and private insurers in order to lessen the financial barriers to broader use of telemedicine. In addition, states can include funding in their annual budgets to convert portions of local department of health facilities to stations dedicated to telemedicine. By doing so, patients without the broadband access needed to use telemedicine will still be able to benefit from enhanced coverage requirements.
Mobile clinics represent an additional opportunity for states to lead in the expansion of rural health care access. Researchers at the American Journal of Managed Care define mobile clinics as “customized vehicles that travel to the heart of communities, both urban and rural, and provide prevention and healthcare services where people work, live, and play. They overcome barriers of time, money, and trust, and provide community-tailored care to vulnerable populations.”65 The clinics provide a variety of services: 42 percent provide primary care services, and 30 percent offer dental services.66 These clinics are incredibly effective at improving health outcomes, particularly among populations who would otherwise have no access to health care providers. For example, mobile clinic patients in Baltimore were more than 6.5 times more likely to receive an HIV screening than patients receiving care from a traditional clinic in the city.67 In Louisiana, 30 percent of high blood pressure patients saw their blood pressure decrease after receiving care at a mobile clinic.68
Share of high blood pressure patients in Louisiana who saw their blood pressure decrease after receiving care at a mobile clinic
In addition to these health benefits, mobile clinics are cost-effective. For many of the populations that mobile clinics serve, emergency departments are the most likely source of care due to lack of insurance and other systemic barriers to traditional health provider access.69 As a result, mobile clinics can significantly reduce avoidable emergency department visits. Data from Family Van, a Massachusetts mobile clinic, estimate that from January 2010 to June 2012, the clinic’s services helped patients avoid more than 2,850 emergency department visits, resulting in statewide savings of approximately $1.4 million.70 Similarly, a comparison of costs between patients treated at a mobile acute care clinic and a traditional acute care clinic for the elderly in New York City found that mobile patients had hospital stays an average of 1.6 days shorter and averaged 31.6 percent lower costs.71
Despite these benefits, mobile clinics face significant financial barriers to operation. They overwhelmingly serve uninsured patients72 and therefore rely on third-party funding sources to cover the costs of providing care. For most of the country, mobile clinics are funded through private donations as opposed to state funds.73 In cases where state funding is present, the mobile clinics are largely funded through state universities—particularly those with associated hospital systems. For example, the Mobile Clinic Project in Los Angeles receives its state funding through the University of California, Los Angeles, and Range Health in Spokane, Washington, receives its funding through a Washington State University College of Medicine grant.74
While the low levels of state funding are not uncommon, they further contributes to the lack of mobile clinic expansion. According to a survey by the National Health Care for the Homeless Council, 58 percent of mobile clinics reported a “lack of financial capacity” as the most significant obstacle they face.75 This lack of funding is especially felt by rural clinics. Prior to the COVID-19 pandemic, fewer than 45 mobile clinics primarily serving rural communities received state funding, and these clinics were largely clustered in Washington state, Virginia, Hawaii, and states within New England.76 Boosting state funding to these clinics can help promote their expansion in rural communities.
In addition to providing direct funding, states can pressure hospitals to dedicate support to these clinics. This could be done through a Medicaid performance metric, for example, that positively scores hospitals that operate or help fund rural mobile clinic programs. Expanding the range of mobile clinics would help reduce the number of uninsured patients that hospitals treat by expanding access to preventive care. Therefore, hospitals would still come out ahead under this funding approach, which is similar to hospital associations offering to pay for Medicaid expansion costs in some states.77 Establishing a new funding stream to support mobile clinics would be an effective and efficient method of increasing access to health services in rural communities.
Expanding rural health care access can take a variety of forms. Policies that help to ensure the affordability of medical practice—including financial assistance for medical and dental students’ education and providers’ malpractice insurance—will expand the health care workforce. Importantly, however, these programs should be tailored to ensure that this new supply is directed toward rural communities. To that end, the scopes of practice for advanced practice registered nurses, physician assistants, and dental health aide therapists should be expanded in order to allow for greater supply of providers in rural communities. Additionally, telemedicine parity and mobile clinics can increase the supply of nontraditional provider settings and deliver high-quality, accessible care in rural communities.
The lack of rural health care access is a problem, but it is one that states have many options to address. The federal government and states made some progress in response to the coronavirus crisis, such as expanding telemedicine access and scope of practice for nonphysician employers. To advance equitable rural health access, they should work on expanding these reforms and consider making many of these changes, such as increases to the federal loan repayment program, permanent. State policymakers have a variety of options to help ensure that rural communities have access to the health care services they need.
* Correction, February 15, 2022: This report has been corrected to accurately describe the National Health Service Corps’ State Loan Repayment Program (SLRP).