Federal policymakers have been trying for a long time to lure more primary care providers to understaffed areas. The Biden administration boosted funding in 2022 to address shortages and Sen. Bernie Sanders (I-Vt.) pushed sweeping primary care legislation in 2023.
But when KFF Health News set out last year to map where the primary care workforce shortages really are — and where they aren’t — we encountered spotty data and a whole lot of people telling us the absence of better information makes it hard to know which policies are working. Turns out, consistent national data is a pipe dream.
We analyzed the public data that does exist: the federal government’s official list of primary care health professional “shortage areas,” created to help funnel providers where they’re most needed. We found that more than 180 areas have been stuck on the primary care shortage list for at least 40 years.
Here’s a map:
“There’s no government organization that’s tracking: Who trained in what, where, and where are they now, and what are they practicing?” said Alison Huffstetler, medical director of the Robert Graham Center, a think tank in Washington that focuses on primary care. “If we don’t know who is doing what kind of care — and where — then there is no way for us to equitably manage the patient-to-clinician ratio across every state.”
Shortage areas get a bunch of carrots to lure medical providers, including federal student loan repayments, bonus Medicare payments and expedited visas for foreign clinicians.
The fact that areas have languished on the shortage list is not because of a dwindling supply of doctors. According to the Federation of State Medical Boards, the number of licensed U.S. physicians more than doubled from 1990 to 2022, to over 1 million, outpacing overall population growth.
A Health Affairs study published in November shows the federal designations, which help allocate an estimated $1 billion in annual funding through at least 20 federal programs aimed at boosting primary care capacity, haven’t meaningfully nudged up the provider-to-population ratios.
One possible explanation for the persistence of shortage areas is that the incentives are too small or too fleeting, said Justin Markowski, a Yale School of Public Health doctoral student, who co-wrote the Health Affairs study.
But another crucial issue is how shortages are measured.
It’s up to state health authorities to identify populations and locations that might qualify as shortage areas and submit them to the Health Resources and Services Administration, which then scoresthe extent of any shortages. The funding and staffing for those state offices vary, creating an uneven foundation.
Further, the main metric for identifying shortage areas, the doctor-to-population ratio, has a glaring weakness. It considers only physicians, not the myriad other health-care professionals, like physician assistants and nurse practitioners, who provide much of our nation’s primary care.
Take Costilla County in southern Colorado. It was deemed a primary care shortage area in 1978 and hasn’t left the list since. It’s true the area could use more clinicians. But it’s also true that federal data has overlooked providers who are there, like the nurse practitioner who has been driving in from the nearest city once a week to see patients, or the physician assistant who just relocated from Texas to fill the gap more permanently.
Since 1998, federal officials have made three attempts to update the 1970s-era rules that define shortage areas. Most recently, the authors of the Affordable Care Act created a committee of experts to figure it out.
When that failed, Colorado came up with its own health professional shortage area designations, which factor in nurse practitioners and physician assistants.
“It’s so important for the nation to target its resources to the highest-need communities,” said Ed Salsberg, who was the lead federal government representative on the ACA-created committee and who headed HRSA’s National Center for Health Workforce Analysis. “It’s time again to try one more time to develop an improved methodology.”
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