Kelly Emrick, Ph.D., DHSc(c), MBA

As of the most recent data, approximately 20% of the U.S. population lives in rural areas. This figure is based on the 2020 Census, which reported that rural areas, defined by the Census Bureau as any territory outside of urban areas with 5,000 or more residents or 2,000 or more housing units, accounted for about 66.3 million people out of a total U.S. population of roughly 331 million. This translates to around 20.0% of the population. However, estimates can vary slightly depending on the definition of “rural” used—such as the World Bank’s 2023 estimate of 16.7% or other sources citing figures closer to 17-19% based on earlier data or different criteria. Given the continuous updates to my knowledge base and aligning with the 2020 Census, the 20% figure is a reliable and current approximation as of February 21, 2025.

Rural populations in the United States face significant health disparities, consistently ranking lower on health indicators such as life expectancy and preventable mortality compared to urban residents. While it is widely recognized that rural communities encounter barriers to accessing health care, the specific challenges providers face in delivering care remain less understood. To shed light on this issue, a qualitative study was conducted by Maganty et al. (2023) in Pennsylvania, home to the third-largest rural population in the U.S., to explore the perspectives of primary care physicians practicing in rural areas.

Hypothesis (Research Objective): Unlike quantitative studies that test specific hypotheses, this qualitative research explores an overarching research question: “What are the barriers to providing health care in rural Pennsylvania as experienced by primary care providers?”

The objective was to identify these barriers and define actionable insights that could guide policymakers in improving care for rural populations. Rather than testing a predefined hypothesis, the study sought to uncover themes directly from providers’ experiences, offering a deeper understanding of the challenges and potential solutions. The study utilized a qualitative approach, conducting semi-structured interviews with 20 primary care physicians practicing in rural counties of western Pennsylvania. Participants were selected using:

• Purposive sampling: Targeting physicians from rural or federally qualified health centers.
• Snowball sampling: Leveraging recommendations from initial participants to identify additional interviewees.

Interviews continued until thematic saturation was achieved, three consecutive interviews yielding no new information, consistent with expectations of reaching saturation after 15–20 interviews. Conducted by a single researcher, each 30-minute interview was audio-recorded, transcribed verbatim, and analyzed using thematic analysis. Two qualitative specialists developed a codebook, ensuring reliability with a Cohen’s kappa score of 0.68 (indicating substantial agreement), and the research team collaboratively identified key themes. The following were the participant characteristics:

• Demographics: 18 men and 2 women, reflecting the underrepresentation of women in the rural healthcare workforce.
• Experience: Ranged from 2 to 25 years in rural practice.
• Affiliation: 55% (11 participants) were affiliated with larger health systems, while all maintained community-based practices.

The University of Pittsburgh Institutional Review Board approved the study, and all participants provided informed consent. Thematic analysis revealed three primary barriers to rural health care from the providers’ perspective:

1. Cost and Insurance: Financial challenges impacted both patients and providers:

• Patient Struggles: Despite many being insured (e.g., through Medicare or Medicaid), high deductibles and co-pays limited access to care. For example, patients dropped out of addiction treatment programs due to costs like urine drug screenings. Specialists often rejected Medicaid, forcing patients to travel further for care.
• Provider Constraints: Clinics struggled to afford staff or ancillary services (e.g., social work, care coordination) due to low reimbursement rates and competition from larger health systems. One provider noted the delicate balance of staffing: “Over or understaff by half a provider… it might be the difference between keeping your doors open or not.”

2. Geographic Dispersion: The vast distances in rural areas created significant access issues:

• Travel Burden: Patients faced round trips of up to 4 hours, exacerbated by a lack of public transportation and poverty. Some walked miles or relied on family for rides, while others missed appointments.
• Time and Cost: Travel required many to take an entire day off work, a prohibitive sacrifice. One participant highlighted, “They must have a vehicle to get them there… it’s very cost prohibitive.”

3. Provider Shortage and Burnout: A scarcity of healthcare professionals compounded other barriers:

• Recruitment Challenges: Attracting providers to rural areas was difficult, with new physicians often leaving after short contracts due to heavy workloads.
• Burnout: High patient volumes overwhelmed existing providers, reducing care quality. One physician described 15-minute visits as insufficient to address complex psychosocial needs, stating, “The system is not geared to actually dealing with the problems that are out there.”

Participants proposed several strategies to mitigate these barriers:

1. Subsidizing Services: Financial assistance for patient costs (e.g., clinic visits, medications) and clinic operations could improve access and sustainability.
2. Mobile and Satellite Clinics: Care was brought closer to patients via mobile units or satellite locations, though staffing remained a challenge.
3. Telehealth: Used for specialty care (e.g., dermatology, psychiatry) but limited by unreliable internet access and inability to perform physical exams.
4. Advanced Practice Providers: Nurse practitioners and physician assistants could alleviate shortages, though recruiting them to rural areas was also tricky.
5. Improved Infrastructure: Enhancing ancillary services like social work and care coordination to address broader patient needs.

The study’s findings suggest several actionable steps to improve rural health care. Policy Recommendations:

• Financial Support:
  • Subsidize patient costs (e.g., co-pays, medications) through state or federal programs, as seen in states like Minnesota and California.
  • Implement models like the Pennsylvania Rural Health Model, providing predictable funding to rural clinics to enhance services tailored to community needs.
• Transportation Solutions:
  • Invest in medical transit services, ride-sharing reimbursements, or volunteer driver programs (e.g., Oregon’s tax credit model).
  • Partner with community resources to reduce missed appointments, as Missouri’s cost-effective transportation initiative demonstrated.
• Provider Recruitment and Retention:
  • Offer incentives beyond loan forgiveness, such as higher reimbursement rates, housing stipends, or burnout prevention programs.
  • Expand training pipelines for rural medical students, who are more likely to practice in these areas.
• Telehealth Expansion:
  • Increase reimbursement for telehealth and invest in broadband infrastructure to ensure rural connectivity.
• Clinic Infrastructure:
  • Fund ancillary services (e.g., nurse navigators, mental health support) to address psychosocial needs and reduce emergency department overuse.

Research Directions

• Evaluate the effectiveness of proposed solutions (e.g., telehealth, mobile clinics) in diverse rural contexts.
• Incorporate patient and policymaker perspectives to complement provider insights.
• Assess the scalability of interventions across states with varying rural demographics and policies.

The research by Maganty et al. (2023) highlights the multidimensional barriers to rural health care, cost and insurance limitations, geographic dispersion, and provider shortages, each reinforcing the others to hinder access and quality. While focused on Pennsylvania, these findings resonate with broader rural health challenges, offering valuable lessons for national and international contexts. Addressing these issues requires a holistic approach: subsidizing costs, improving transportation and infrastructure, and bolstering the provider workforce. Despite limitations, such as its small sample size and regional focus, the study provides a critical foundation for reducing rural-urban health disparities through targeted policy and practice innovations.

Citations

Maganty, A., Byrnes, M. E., Hamm, M., Wasilko, R., Sabak, L. M., Davies, B. J., & Jacobs, B. L. (2023). Barriers to rural health care from the provider perspective. Rural and Remote Health, 23(2), Article 7769. https://doi.org/10.22605/RRH7769