States Are Trying to Get Rural Health Workers to Stick Around

The hospitals in rural Illinois need more doctors. They’re short on everything from nurses and primary care physicians to gynecologists, psychiatrists, general surgeons and more.

“There's a huge behavioral health crisis happening in rural [areas],” says Hana Hinkle, director of the National Center for Rural Health Professions at University of Illinois College of Medicine Rockford (UIC). Hinkle says obstetricians and other “specialty care” providers are in the most critical short supply at critical access hospitals, followed closely by primary care. “Unfortunately we are still a long way off from being able to meet all the need that we have for workforce development, especially in rural and underserved areas.”

There are lots of reasons it’s hard to get health-care providers to settle in rural areas. Geographically isolated locales often don't appeal to large numbers of would-be physicians looking for a place to open a practice or find a well-compensated job that can pay down their student debt. Economic opportunities for the spouses and partners of health-care providers are also more scarce in rural areas, Hinkle says. “It’s great if the hospital has an amazing sign-on bonus and things like that for the physicians, but you also have to look at the family unit as well,” Hinkle says.

The American Medical Association (AMA) reported in 2024 that 65 percent of rural areas had a shortage of primary care physicians. Most rural counties in the U.S. don’t have even one psychiatrist, and the problem may only get worse: with each year many more psychiatrists retire than enter the field, says Kari Wolf, CEO of the Behavioral Health Workforce Center at Southern Illinois University. There are so few clinics and primary care practices across rural America that residents risk losing access to care if one place closes or stops accepting Medicare, according to the AMA.

States have been taking aim at the problem, with several strategies directed at building the pipeline of rural health-care workers. Many of these strategies attempt to mitigate the challenges health-care practitioners face when they’re serving rural areas.

Colorado’s Corps

Doctors in rural areas often have particularly heavy workloads, with both for- and nonprofit facilities pressing them to log as many billable hours as possible to make the balance sheets work. That’s in part because facilities caring for underserved patients may have slimmer margins, as government payer insurance plans tend to compensate providers at a lower rate than private insurance.

That lower revenue means less funding for hiring and fewer staff to shoulder the workload. Because of this, in addition to working a full workweek, practitioners in less monied areas are often on call for the emergency department during their time off, making it easy to get burned out, says Steve Holloway, director of the primary care office at the Colorado Department of Public Health and Environment. 

At the same time, Colorado and other states expect they’ll need to provide more health-care services than ever as the U.S. population gets older.

In response, Colorado created the Colorado Health Service Corps, a loan repayment program that helps participants with student debt if they commit to spend several years in underserved areas directly caring for patients, regardless of ability to pay.

“It is becoming more and more common that physicians and dentists who apply to our program have as much as $300,000 in student loan debt, sometimes even higher than that,” Holloway says.

Colorado’s Corps currently has 550 participating clinicians, making it the largest state-based program. Since the program’s launch in 2009 roughly 200,000 people have participated, with fewer than 0.5 percent trying to renege on their agreements.

Loan repayment programs often are criticized as a temporary fix, because participants may just leave when their obligation ends. But Colorado has been trying to find people who will stick around. The program looks for applicants driven by a mission to help underserved people. Holloway has found that clinicians able to practice in languages beyond English are more likely to continue on working with underserved patients, whether in rural areas or elsewhere, and that applicants who studied in Colorado are more likely to remain in the state.

Staff also talk Corps applicants through what the service commitment means, hoping to discourage anyone who isn’t truly up for it: “We kind of joke internally that our job is to talk people out of taking the money [for loan repayments].” In most application rounds, about two to three people back out.

Currently, about 70 percent of participants continue serving in the area for a year after their three-year contract ends. Some also opt to renew participation in the program in exchange for more debt forgiveness: during the past five years, the portion of eligible participants renewing has ranged from a high of 78 percent in September 2020 to a low of 22 percent in September 2021. (The department notes that some may choose not to renew simply because they have little debt left to pay off, and not necessarily because they’re moving away from an underserved community.)

Illinois’ Rural Education

University of Illinois College of Medicine Rockford is aiming to build its rural medical workforce with an education program specifically on rural medicine, which supplements the standard medical school curriculum. That program began with a cohort of four in 1993 and has since graduated 271 physicians.

Like the Colorado Health Service Corps, the Rural Medical Education program seeks applicants with the drive to stay in underserved communities long-term.

Hinkle — of the UIC’s National Center for Rural Health Professions — looks for students who are from rural areas or who are driven by a service mission and who may have had a “transformative experience” helping in a rural area. “How involved were they in that community setting before? How close are they tied to wanting to serve the underserved?”

So far, 75 percent of Rural Medical Education program graduates have gone on to serve in towns with fewer than 20,000 people, and they’re almost 10 times more likely than the university’s other graduates to practice in communities experiencing a shortage of primary care, the institution reports. They stay an average of eight to 10 years in their first practice location, Hinkle says. That’s especially significant given that, unlike some other initiatives states have tried, this program doesn’t offer financial incentives for practicing in rural areas.

The National Center for Rural Health Professions also tries to build talent locally in rural areas, hoping to interest high school students in future health-care careers in their own communities. Summer programs can include experiences like shadowing at local hospitals and hands-on learning. The programs aim to reach students who may not have considered such professions and get them aware of the career paths available. About 40 percent of high school students who participate in the three-day overnight Rural Health Careers Camp go on to work in health care, Hinkle says.

Launching a Career

People tend to practice within 30 to 50 miles of where they do their clinical training, says Wolf, of the Behavioral Health Workforce Center in Illinois. But that can lead to a self-reinforcing problem: If a new graduate from medical school cannot find a rural community with a supervisor in their discipline whom they can train under, that graduate likely won’t end up practicing there. So the community continues not to have practitioners who might work as supervisors in the future.

The Behavioral Health Workforce Center is readying a new initiative to help address this: remote supervisors who can videoconference in to discuss caseloads with social workers in training, observe and advise on psychiatry residents’ sessions with patients and otherwise fill the role, even if they’re based in a different community.

Working in a remote facility can also be isolating for practitioners who are the only one there in their field. The Behavioral Health Workforce Center plans to offer regular lunchtime video calls that will discuss clinical topics and connect young medical professionals with peers in other locations. The effort aims to create community to support young professionals both during residency training and when they launch their careers.

“When you're early in your independent career, that's when that isolation can be most damaging” and can lead some to depart for areas with more colleagues, Wolf says.

While there are plenty of challenges facing health-care practitioners who go into rural areas, Hinkle notes that there are also opportunities. Rural facilities are less likely to be able to refer out cases to a network of subspecialties, but this in turn means physicians get to handle a wider array of events themselves. And, unlike their urban counterparts, rural physicians may get to have connections with their patients that are “a lot richer.”