Federal Efforts To Improve Primary Care Access in Underserved Communities Fell Short, Researchers Find

Supply of Primary Care Physicians Remained Unchanged or Worsened From 2010 to 2019, Despite Billions in Federal Funding

BOSTON – When the comprehensive health care reform law known as the Affordable Care Act was enacted in 2010, it sought to eliminate the barriers preventing many Americans from accessing health care — primarily by making health insurance available to more people. But after health care coverage, a lack of physicians — particularly primary care physicians (PCPs) — remains a major barrier to care in many poor and/or rural communities. As such, in 2011, the federal government invested more than $11 billion aimed at expanding the PCP workforce in underserved communities.

In a paper published in JAMA, researchers used national data to study how the supply of primary care physicians has changed over the past decade across the United States by key county-level characteristics, including concentration of racial and ethnic minorities, poverty, rurality, and geography. The team found that despite recent federal investments, the supply of PCPs has not meaningfully changed in the poorest counties and those with the highest concentration of racial and ethnic minorities.

“In fact, the number of primary care physicians per 100,000 residents has fallen in rural and southern counties,” said senior author Rishi Wadhera, MD, MPP, MPhil, section head of Health Policy and Equity Research at the Smith Center for Outcomes Research at Beth Israel Deaconess Medical Center. “These findings are very concerning because PCP supply is associated with population-level health and mortality. PCP shortages could in turn contribute to inequities in health care access and outcomes across the United States.”

Wadhera and first-author Michael Liu, MPhil, of Harvard Medical School (HMS), gathered data on the number of PCPs under the age of 75 in all 3,142 U.S. counties and the demographic characteristics of those counties. Next, focusing on counties with the highest proportion of Black and Hispanic individuals, counties with the lowest incomes, and rural counties, the team calculated the annual county-level supply of primary care physicians per 100,000 people over the past decade.

Analyses revealed that the number of PCPs per capita did not change in the top ten percent highest-proportion minority counties versus the remaining counties between 2010 and 2019. The inequities between the two groups persisted over the study period. Likewise, there was no change in the supply of PCPs in the very poorest counties, and disparities between the very poorest and wealthiest counties remained unchanged during the study period.

Concerningly, the number of PCPs decreased in rural counties during the study period, but remained stable in urban counties, resulting in a significantly widening rural-urban gap. Southern counties also consistently had the lowest PCP supply per 100,000 residents and experienced significant declines between 2010 and 2019, while no changes were observed in other geographic regions.

The authors note that these data reflect a troubling shortage of physicians that was apparent prior to COVID-19 and suggest the pandemic has only exacerbated the problem.

“The COVID-19 pandemic has certainly worsened the PCP shortage crisis and likely further exacerbated disparities in underserved communities,” said Wadhera, who is also an assistant professor of medicine at HMS. “Emerging data demonstrates an exodus of health care workers including PCPs in the US, and there are concerns about the long-term impact of the pandemic on the diversity of the physician workforce.”

“We hope our findings help spur further action from health system leaders and policymakers,” said Liu. “Current policies, including funding allocated to bolster the primary care workforce in these communities, are likely necessary but not sufficient to achieve this goal. Other evidence-based interventions should be considered to help recruit and retain PCPs in underserved communities, such as alleviating educational debt, recruiting more students from underrepresented backgrounds, and increasing opportunities for students to train in underserved communities such as rural counties.”

This work was funded in part by the National Heart, Lung and Blood Institute (grants R01HL164561 and K23HL148525). Wadhera reported receiving personal fees from CVS Health and Abbott. No other disclosures were reported.