Ten years ago, state Rep. Kent Haden’s rural northeastern Missouri district had a thriving medical community. Dozens of doctors and hundreds of nurses and other staff lived and spent money in the area, while working at two hospitals in Mexico and Fulton.
But that all changed when a private equity-backed startup bought the hospitals and shut them down in 2022. Not only did the area lose two of its largest employers, but Haden’s community lost much of its medical care.
“A lot of people have died from this: Wrecks, heart attack, strokes, babies,” Haden said. “It's a catastrophic deal to a community.”
Haden said the turnaround time for ambulances rose from an hour to two hours. People now have to drive miles farther to go to the doctor, especially for specialty care.
“We have desperate, desperate needs,” Haden said.
It’s a familiar problem to most of Missouri. The federal Health Resources and Services Administration has designated nearly every county in the state as a “Health Professional Shortage Area” that doesn’t have enough primary care providers to serve its population.
New legislation sponsored by Haden hopes to change that by attracting more doctors, nurses, mental health professionals and public health workers to underserved parts of Missouri. One law,which took effect in August, awards $4.9 million to expand an existing program that repays student loans for health care workers. Another program increases the number of residencies, the mandatory training that medical school graduates receive before they become fully certified doctors.
The goal is to create financial incentives to increase the number of health care providers in Missouri before the shortage gets even worse, Haden said. Graduates of medical school often incur hundreds of thousands of dollars in student debt.
“You've delayed a lot of things,” Haden said. “A lot of times you have children. A lot of times you have a broken-down old car. You have a lot of things (to pay for) that you're basically forced to go where there's higher pay.”
Recruiting challenges
It’s hard to attract workers to rural areas in general, said Heidi Lucas, executive director of the Missouri Rural Health Association. Areas with higher populations have higher salaries, more job opportunities for workers’ spouses and more options for their kids’ schools.
Health care workers who move to rural areas may leave within a few years if they aren’t able to build new social ties, Lucas said. One possible solution is for employers to help new hires join community organizations and other social groups so they can make friends.
“If they’re not able to create a community for themselves within that area,” Lucas said, “a lot of the time it does take them back to the urban areas.”
In addition, Missouri’s regulations surrounding advanced practice registered nurses are more restrictive than those in other states, Lucas said. This leads to nurse practitioners leaving to work in other states, like Kansas, which recently gave APRNs more independence to practice on their own.
Rural health care workers also have higher workloads and less time off, said Aleesha Jones, primary care office manager at the Missouri Department of Health and Senior Services’ Office of Rural Health and Primary Care. The state’s new loan repayment program is intended to make life easier for people working in these conditions.
“There's just not a lot of amenities or other things in those areas,” Jones said, “which is why it's important for us to implement these programs and give them incentives.”
A new program
Missouri previously had loan repayment programs for nurses and medical students going into primary care. The programs received about 200 applications a year, but the state could only fund between 50 and 80 of them, Jones said.
The new program will include a wider variety of health care providers, including those working in mental health and public health. Workers must stay in an underserved area for at least two years to receive the money.
The state health department is still determining how the money in the program will be distributed, how many people will receive loan repayments and how much money each person will receive, Jones said.
“It will allow us to look at workforce trends and see where we have the greatest need,” Jones said.
Another new law, also sponsored by Haden, will provide about $2.4 million in state funding for residency programs in family medicine, internal medicine, psychiatry, obstetrics and gynecology and pediatrics.
In 2022, Missouri was ranked ninth in the nation for total number of medical school graduates, graduating almost 1,100 people. But the state only has about 600 residencies available for new graduates, said Dr. Heidi Miller, chief medical officer of the Missouri Department of Health and Senior Services. And physicians often stay in the same places where they went through residency.
“We’re exporting about a third of our medical school graduates,” Miller said.
In addition, the COVID-19 pandemic resulted in experienced health care providers retiring early or otherwise leaving the field. A 2021 survey of Missouri primary care professionals found that more than half of respondents experienced burnout during the pandemic. Losing colleagues can create more stress for the providers who stay behind. And that can cause even more people to quit.
“Health care is a really challenging field. It can be demoralizing,” Miller said. “If you lose team members or you don't have enough team members, it requires the remaining team members to overwork.”
Ultimately, it’s patients who suffer due to a shortage of providers, and it’s patients who will benefit from an increase, Miller said.
“It also perpetuates health disparities where folks who are more affluent and more privileged will be able to transport themselves to a physician,” she said. “And folks who can't, will get sicker.”
