Rural America is facing a massive and growing shortage of physicians. For the past few decades, doctors have flocked to cities seeking better career opportunities, higher pay, and urban amenities. As a result, only 10% of physicians now live in rural areas, compared to 20% of the overall U.S. population. This maldistribution has potentially disastrous consequences: studies have shown that having physical access to a doctor is an important determinant of health. For many rural Americans, getting this access requires a long drive and a potentially longer wait, resulting in potential health consequences such as a higher likelihood of infant mortality, obesity, and disability. The shortage and its effects are likely to get worse in the coming decades, as an increasing percentage of physicians choose to practice in urban areas.

In response to this crisis, policymakers have implemented two primary measures designed to stem the flow of physicians moving to urban areas. First, the Department of Health and Human Services and others have created wage incentives for doctors practicing in shortage areas. These incentives are designed to attract new doctors to rural areas by offering them a slight wage premium, and to keep rural doctors rural by offsetting their opportunity costs. Second, many medical schools have opened rural branch campuses or programs, ostensibly designed to accustom students to rural life and erode their preference for urban areas.

The assumption of these policies is that doctors live in urban areas simply because they prefer higher density and urban amenities. Unfortunately, this assumption is incomplete and misinterprets the nature and causes of the rural doctor shortage. The rural doctor shortage is not a result of rurality per se, but rather of the urban/rural education and class divide. In short, doctors have an overriding preference for urban areas because urban areas, like doctors, tend to be richer and more highly educated than rural areas. Current policies aimed at changing this preference have been unsuccessful because class is largely an immutable characteristic. Paying doctors more in rural areas will not override their desire to be around other doctors and highly educated people. Instead, policymakers concerned about the rural doctor shortage should focus on recruiting doctors with pre-developed preferences for rural areas and on finding appropriate doctor substitutes, such as nurse practitioners.

Maintaining current policies will waste millions of dollars and do little to ameliorate the rural doctor shortage or improve rural health. Policymakers should pivot toward a new set of policy solutions based on a more nuanced understanding of the shortage and its causes. To that end, the rest of this document is split into three parts: first, describing where the shortage is and what its causes are; second, discussing why current policies have failed; and third, offering new potential solutions.

Mapping the U.S. Doctor Shortage

Effective policy responses begin by correctly identifying the problem they’re trying to solve. Policymakers, health professionals, and academics have spent decades studying the spatial distribution of physicians. As early as the 1960s, academics such as Rimlinger and Steele (1961) lamented the shortage of rural U.S. physicians and its potential impact on rural health. Since then, countless academics have updated the methods used for quantifying the shortage, but their shared description of the shortage as being rural has remained the same (where rural typically means lower population density).

Unfortunately, this definition is incomplete. While it’s generally true that rural areas have fewer doctors, there are also rural areas with a high number of doctors relative to their population. These oversupplied areas aren’t just small anomalies, they often encompass entire regions of the United States. The map below shows the physician-to-population ratio (physicians per 100K people) of each U.S. state. The ratio is grouped into quantiles for easier viewing. Most rural southern states (Mississippi and Arkansas) and plain states (Iowa, Nebraska) do have a low number of doctors relative to their population. However, notably rural regions such as the Pacific Northwest (Washington, Oregon) and the far Northeast (Maine, Vermont) are oversupplied.

This distribution indicates that the rural doctor shortage is not driven entirely by rurality, but rather by a combination of rurality and other factors such as educational attainment level. Research shows that educational attainment explains over 40% of the variation in physician supply, while population density (rurality) explains less than 10%. In other words, the rural doctor shortage may be better characterized as a doctor shortage in less-educated areas. Rural areas do have doctor shortages, but they’re largely caused by rural areas being less-educated, rather than by rurality itself. Thus, policymakers have misidentified the cause of the shortage, attributing it to rurality when the truth is likely more nuanced.