Mobile health clinics are combating maternity care deserts in Florida

An OB/GYN mobile outreach clinic directed by researchers Adetola F. Louis-Jacques, Arielle Ayotte, and Michelle Nall at the University of Florida is helping to address a maternity care desert in north-central Florida, they report for The Conversation.

Nationwide, 2.5 million, or 4%, of American women of childbearing age live in a maternity care desert, they report. A maternity care desert is any county with no hospital, birthing center or obstetric health care professional. “Women in maternity care deserts travel an average of 35 miles to reach a birthing hospital, compared to an average of 9 miles for women in full-access counties.”

Traveling longer distances for obstetric care is directly correlated with poorer infant and maternal health outcomes, studies show.

Florida counties with full, low, or no access to maternity care. 
(Map via The Conversation CC, data from March of Dimes 2023 statistics, Click to enlarge)

In Florida, only three of the 14 north-central counties have full access to obstetric care, the researchers explain, and six have low access. The other five counties are deserts that they estimate to have 3,400 women of childbearing age. They also found in a 2024 report that 18 of Florida’s 21 rural hospitals have no more obstetric care, often because of a lack of funding.

Their new mobile clinic, started in February last year, offers prenatal and postpartum care, breastfeeding support, family planning, annual gynecological exams and preventive health screenings. They have already cared for 194 women in 616 visits.

Everything is free to the patients, and they offer assistance to help eligible patients apply for Medicaid benefits. “In 2023, about 1 in 7 women of childbearing age in Florida were uninsured,” they report.

A survey of mobile clinic patients across the U.S. found they “reported receiving holistic care, feeling safer than they’d felt in other health care settings and interacting with staff who were mindful of health care costs,” as well as being able to “maintain continuity of care.”

Most mobile clinics don’t offer maternal and infant health services, the researchers explain, and as maternity care deserts grow, more OB/GYN mobile health clinics like this one can directly provide low-income, rural areas with regular prenatal and postpartum care that women wouldn’t have access to otherwise.

Opinion: Rural Americans rely on immigrant physicians for care, but new restrictions will leave them with fewer doctors

Rural hospitals have relied on foreign-born doctors
to provide care for decades. (MedPage Today photo)

Rural communities already struggle to staff their hospitals and clinics with physicians of all types, from specialists to family practitioners. The Trump administration's failure to make progress on immigration changes and the newly established $100,000 fee for each new H-1B visa application, which has no exemption for health care workers, will leave rural Americans with far fewer doctors to treat them, writes Manav Midha in his opinion for MedPage Today.

The difference in the number of physicians and the availability of specialists between urban and rural locations is stark. Midha writes, "There are approximately 263 specialists for every 100,000 people in urban areas compared to 30 for every 100,000 people in rural areas, and 46% of counties (and 86% of rural counties) have not a single cardiologist."

For decades, rural communities have relied on immigrant doctors for their care. Midha explains, "Foreign-born physicians are uniquely willing to serve rural communities even when few others move there. Immigration restrictions risk cutting off one of the last remaining lifelines for rural healthcare access."

Immigrant doctors who came to the U.S. in the 1980s and 1990s were able to obtain J-1 visas, which "allow for a path to permanent residency if a doctor works for at least 3 years in an area with underserved healthcare needs," Midha adds. They cared for patients in "rural Indiana, deep Appalachia, coastal Louisiana, and parts of Texas, hours from the closest city," where few American graduates wanted to live.

Congress could expand the Conrad 30 program to add some physicians with J-1 waivers who can treat in rural communities. "The bipartisan Conrad State 30 and Physician Access Reauthorization Act would have expanded (albeit slightly) the number of spots and extended the program. It was initially introduced in Congress in 2023 and again in 2025 but has seen little movement," Midha writes.

In the face of the current shortage, some states are developing their own approaches to help rural communities secure access to doctors. Midha writes, "At least 18 states, led by Tennessee, have enacted laws permitting internationally-trained physicians with appropriate experience to practice medicine without having to repeat medical residency."

Meanwhile, some rural communities may face a more severe shortage of physicians, and residents will have to travel longer distances for care. Expanding and developing paths for immigrant physicians "is not merely a moral imperative -- it is an economic one," Midha adds. "And it is one that can address one of the greatest challenges to equitable care."

Report: Rural primary care physician shortages will persist for at least another 12 years

Graph by Celli Horstman and Arnav Shah, State of Rural Primary Care in the United States, Commonwealth Fund

Rural residents will continue to grapple with a shortage of primary care doctors for at least another 12 years, according to a report issued last week by the nonprofit Commonwealth Fund.

Using federal health workforce data, researchers concluded that "rural areas will continue to have only about two-thirds of the primary care physicians they need," reports Nada Hassanein for the Wisconsin Examiner. Report authors noted that the persistent shortage of primary care doctors leaves million of rural residents "with fewer options for routine and preventive care."

The report's release came just days after the window closed for hospitals to apply for a share of the $50 billion federal Rural Health Transformation Program administered by the Centers for Medicare & Medicaid Services. Hassanein writes, "Some states want to use the federal money to expand their rural residency programs, as physicians who complete their residencies in rural areas are more likely to practice in one."

Nearly all of the more than 40 million rural Americans live in areas with primary care physician shortages, according to the report. "Forty-five percent of rural counties had five or fewer primary care doctors in 2023," Hassanein adds. "Roughly 200 rural counties lacked one altogether."

The report found that doctor shortages in rural areas vary by region. Hassanein writes, "States in the South had 3,411 patients per physician, whereas states in the Northeast had 1,979 residents per physician."

Although rural areas will continue to lack enough primary care physicians, some of the gap will be filled by rural nurse practitioners. Hassanein adds, "Nurse practitioners are the fastest-growing type of clinician in the U.S., regardless of geography, the report authors wrote."

Emergency departments in some rural areas don't have 24/7 on-site physician coverage

A hospital in Ekalaka, Mont., sits at the intersection of two dirt roads. 
(Photo by Arielle Zionts, KFF Health News) 

Many rural emergency rooms are no longer run by attending physicians, but instead depend on care by nurse practitioners and physician assistants. "A recent study found that in 2022, at least 7.4% of emergency departments across the U.S. did not have an attending physician on-site 24/7," reports Arielle Zionts for KFF Health News. "More than 90% were in low-volume or critical access hospitals — a federal designation for small, rural hospitals."

The 2022 report represents "82% of hospitals that responded to a survey sent to all emergency departments in the country, except those operated by the federal government," Zionts writes. "The study is the first of its kind, so there isn’t proof that such staffing arrangements are increasing, said Carlos Camargo, the lead author and a professor of emergency medicine at Harvard Medical School."

The idea of an emergency department without a doctor on staff remains controversial, and not all states allow it. "Some doctors and their professional associations say physicians’ extensive training leads to better care, and that some hospitals are just trying to save money by not employing them," Zionts explains. Indiana, Virginia, and South Carolina have passed laws that require all their EDs to have a 24/7 physician on-site.

Even when states require their EDs to staff a round-the-clock doctor, that doesn't make finding one easy. "In the Dakotas, more than half of emergency departments were running without 24/7 attending physician staffing," Zionts reports. In response to the regional shortage, Sioux Falls-based Sanford Health launched an emergency medicine residency to help increase its ED physician numbers.

Some rural health advocates say lawmakers need to be sure that employing full-time ED physicians 24/7 is feasible for their region before passing legislation that requires it. Zionts adds, "Camargo said some doctors say that if lawmakers are going to require 24/7 on-site physician coverage in ERs, they need to pay to help hospitals implement it."

Opinion: A rural hospital administrator considers what will become of his center if Congress cuts Medicaid

When a rural hospital closes, many residents drive hours to
see a provider or receive specialized care. (Adobe photo)

Over the past 15 years, rural hospitals have struggled to stay afloat, but their already precarious financial state could become a full-blown crisis should Congress slash Medicaid spending. Kevin Stansbury, the chief executive of Lincoln Health in tiny Hugo, Colorado, writes in his opinion for The New York Times, "Congress is considering cuts to Medicaid that could wreak havoc on rural America’s fragile health care system. I worry about our future."

Cuts to federal Medicaid support will be hard on most medical centers, but "rural hospitals will be particularly affected," Stansbury explains. "This is because rural patients are more likely to have health coverage from the government than from commercial insurers. (Nearly three-quarters of our revenue, for example, is from Medicaid and Medicare.)"

In Colorado, almost half of all rural hospitals operate in the red and many have closed services such as labor and delivery units because they are too expensive to run. Stansbury writes, "We also serve fewer patients than big city hospitals but still have fixed costs to stay operational. The result is that we run on minimal or negative operating margins."

When a rural hospital closes, the health of its immediate and surrounding communities suffers. If a severe auto accident happens, victims have to wait longer for emergency services to arrive, or brave traveling to the closest medical center. Residents with chronic conditions are more likely to skip regular care because they must drive hours for a checkup or specialty treatment.

"I know the financial peril my hospital will face if our Medicaid lifeline is severed. But the real damage — the kind that keeps me up at night — will be done to the hardworking people in my rural community," Stansbury adds. "I worry about the residents of our nursing home who just want to grow old here. I worry about the people in Hugo who might forgo care entirely because they can’t get the time off work to visit a Denver hospital. . . .The list goes on."

Cutting Medicaid waste and fraud is one thing "but the cuts on the table go far beyond that," Stansbury writes. "I don’t see waste in Hugo. Rather, Medicaid ensures that primary and emergency care is still accessible here, and that drivers along I-70 will see the blue H on the highway sign and know that help is nearby."

New doctors are avoiding abortion ban states, new analysis shows. Restrictions may add to mutiple-care shortages.

Fewer new doctors are applying for residency in
abortion ban states. (Hush Naidoo Jade photo, Unsplash)

States with significant restrictions or bans on  abortions may be inadvertently discouraging graduating medical students from applying for residency in their state, which could exacerbate regional physician shortages. Julie Rovner and Rachana Pradhan of KFF Health News report, "According to new statistics from the Association of American Medical Colleges, for the second year in a row, students graduating from U.S. medical schools were less likely to apply this year for residency positions in states with abortion bans and other significant abortion restrictions."

State battles over abortion aren't limited to uncertainties for doctors and pregnant patients; the tensions have "also bled into the world of medical education, forcing some new doctors to factor state abortion laws into their decisions about where to begin their careers," Rovner and Pradhan write. "Fourteen states, primarily in the Midwest and South, have banned nearly all abortions. . . . A preliminary review of a new analysis by the AAMC found that the number of applicants to residency programs in states with near-total abortion bans declined by 4.2%, compared with a 0.6% drop in states where abortion remains legal."

The AAMC's analysis shows that when new doctors start avoiding certain states, those states gain fewer doctors, which adds to regional physician shortages in many specialties. KFF Health News reports, "The organization tracked a larger decrease in interest in residencies in states with abortion restrictions not only among those in specialties most likely to treat pregnant patients, like OB-GYNs and emergency room doctors, but also among aspiring doctors in other specialties."

The number of new doctors applying for OB-GYN and internal medicine residency slots in those states "dropped 6.7%, compared with a 0.4% increase in states where abortion remains legal," Rovner and Pradhan explain. "For internal medicine, the drop observed in abortion ban states was over five times as much as in states where abortion is legal."

Incoming president of American Medical Association says AMA cares about getting more doctors in rural areas

With new research showing rural Americans are more likely to die early from the five leading causes of death than their urban counterparts, "the American Medical Association is sounding the alarm," reports Melissa Patrick of Kentucky Health News.

AMA President-elect Bruce Scott (AMA photo)

"Rural health is America's health," Dr. Bruce Scott, the AMA president-elect, told reporters in a May 9 press conference in conjunction with the National Rural Health Association annual conference in New Orleans. "We need policymakers to understand that the American Medical Association is deeply concerned about the ever-widening health disparities between urban and rural communities, disparities that are at the root of why rural Americans suffered disproportionately high rates of heart disease, cancer, stroke, respiratory illness, diabetes, and unintentional injuries." 

Scott, who is board-certified in both otolaryngology and facial plastic surgery, will become AMA president in June. He pointed to several environmental, economic and social factors factors that put people who live in rural communities at a higher risk of death from these often preventable conditions. But the AMA's focus, he said, is on the health-care worker and the physician shortage and how this affects rural people's health. 

He added that these shortages are hitting rural areas the largest and are "creating health-care trends that are simply unacceptable. We need to reverse these trends for all individuals to live a long, healthy and active life." Scott said rural areas have about 30 physician specialists for every 100,000 residents, compared to 236 per 100,000 in urban communities, and he noted that more than 130 rural hospitals closed from 2010 to 2021, with many more on the verge of closing today. 

Also, he said that in 2023, 65% of rural communities had insufficient access to primary-care physicians, including pediatricians. And, he said there are not enough residency spots to train doctors in rural areas. "History has shown us that residents, 80% of the time, tend to wind up practicing within 80 miles of where they've done the residency," Scott said. "So residency location becomes very important. In addition, medical schools are receiving fewer and fewer applicants from individuals from rural areas."

Opinion: Why prescription drugs have little to do with the current illicit drug epidemic in the United States

The 1990s marked a time in U.S. medicine where doctors were taught to give narcotics.
(Graphic via Life and Limb blog, Edwin Leap)

Emergency physician Edwin Leap explains that U.S. doctors in training during the 1990s were instructed to treat pain with pills. He said a medical career taught him how misdirected those practices were. He adds that the nation's current addictions and overdoses aren't centered on prescription drugs anymore; they're all about super cheap, available and deadly fentanyl -- other opioids are almost an afterthought. An excerpted version of his commentary from MedPage Today is included below.

"When I was in my residency training, from 1990 to 1993. . . . We were told, over and over, that we should treat pain aggressively and should not be afraid to give narcotics to patients in pain. Who were we to judge someone's pain, after all? The young man who fell onto his knees at work, with a normal blood pressure and heart rate, looking about the room, might well categorize his pain a '10/10,' and we should honor that, respect it, and treat it."

Pain medicines such as hydrocodone and oxycodone (Oxycontin) were first marketed to doctors as a miracle for patients in pain. Given their addictive nature, it didn't take long for the drugs to take hold. Leap writes, "Much of our work as physicians was a balancing act between trying to show genuine compassion, mandated compassion, and appropriate skepticism about pain scales and the lies concocted in pursuit of drugs."

Given doctors' role as the prescription writers who "started" patients on the path to addiction, physicians are now forced to take additional narcotic treatment training. "I have to take a new 8-hour class on proper prescribing habits and pain management," Lead adds. "[But] nobody really argues with me about pain pills anymore. . . .We're only supposed to give a 3-day supply. We tell people that, and they shrug."

The likely reason a 3-day narcotic supply isn't a problem is the availability of fentanyl. "It's just so easy to get the stuff. It's inexpensive, and it's everywhere. It's in drug houses and gas station parking lots. It's in high schools and college campuses," Leap writes. "It's in prisons and homeless encampments. In fact, according to independent journalist Jonathan Choe, it can sometimes be found for 50 cents per dose in homeless camps."

U.S. physicians have little to do with fentanyl's street dominance. Leap writes, "The flood of illegal fentanyl precursors from China, which then become fentanyl and began flowing across the Southern border, continues unabated. . . . It's all rearranging the deck chairs of the Titanic until someone gets a handle on the crisis from a geopolitical standpoint. And yes, that means dealing with the border as well. . . . I'm not blaming one political side or another. I'm just saying that if it isn't taken seriously, then the deaths will keep skyrocketing."

This piece was originally published on Leap's blog, Life and Limb.

Opinion: Recruiting physicians to rural areas needs to show what communities offer, which goes far beyond money

Rural medicine is often more about relationships than diagnoses,
which is a hard concept to incentivize. (UIC photo)

Student loan reductions and payoffs have not enticed enough graduating doctors to move into rural areas. But when medical providers experience working in less populated places, they often find smaller communities have so much more to offer, writes Arjun V.K. Sharma in his essay for Undark. "Strategies to attract doctors to rural areas can take many forms, but it is hard to imagine any being successful without the doctor seeing the benefits of the community in which they reside."

Government officials, public policy writers and community planners would do well to look at what it takes for a resident to opt to live in a rural location. Sharma explains: "Often, it is interminably fraught — already hard work is made harder, significant others are uprooted, and certain city comforts and sensibilities may be sacrificed. Physicians, then, must rely on forces internally summoned — autonomy, altruism, competence — to propel them forward. These qualities are harder to define and measure, which make them difficult to meaningfully pin to any reward."

"When I left the city for work in a rural hospital, I put those virtues to the test. I was unsettled, initially wading through the steady stream of 'hellos,' 'good mornings,' and 'good nights' from passersby in the corridor, and unsure of how to interact with psychiatric patients who ran a café near their small ward to ease their transition to the world outside," Sharma writes. "And I was uneasy, at times, with the care we provided — even if patients were appreciative of what they received. The same decisions we fashioned in the city — to get antibiotics delivered at home or to get a surgeon to clear out an abscess — came together with fewer resources, and with doctors stretched hundreds of miles apart."

Rural settings offer a space where all people intermingle and get to know each other. And the closeness of being together while all others are miles away "lent a power to something decidedly tangible. Interactions with patients had an unflinching honesty and tenderness about them," Sharma adds. "One morning, an older man with anxiety was referred from the emergency department to a senior physician. They ran into each other at the grocery store and at local hockey games; living down the street, the physician would often check in on him."

Sharma writes. "A connection to a rural identity could be bought with incentives, or it could be learned. . . . It could be lived through simple and heartfelt things: a teary 'thank you,' a firm handshake, or the question, over and again, from patients of your plans to stay. These gestures don’t absolve the system of its responsibility to make positive reforms. But they affirm value and purpose of work that, whittled down by staffing shortages and burnout, can still impact lives our society willfully neglects."

Rural areas desperately need more physicians, but even adding residency slots isn't a simple solution

Illustration by Shoshana Gordon, Axios

Rural areas don't have enough physicians because rural hospitals have not been able to add residency slots. Adding more slots may sound simple, but until the Covid-19 relief bill, slots, which are funded through Medicare, were capped. The relief bill added 1,000 residency slots and required 10% of those to be granted to rural hospitals, but few have applied. Maya Goldman of Axios Vitals reports, "Just seven of the 199 hospitals that have received federal dollars for new residency slots in initial funding rounds are in rural areas, federal health officials confirmed."

Because residents are more likely to stay where they completed their training, adding slots is considered the most reliable way for areas to "grow their own" doctors. However, hospitals must have the capacity to go through the slot application process and have the resources to train more physicians. Goldman explains, "A combination of limited infrastructure and staff to run residency programs, as well as a lack of awareness about the funding opportunity, has prevented more hospitals from applying, said Carrie Cochran-McClain, chief policy officer of the National Rural Health Association. . . ."

Part of the reason more funding has gone to more urban hospitals is because of a reclassification loophole. "The 2021 law requires that 10% of new Medicare-funded residency slots go to rural hospitals or hospitals that are 'treated as being located in a rural area," Goldman reports. "That wording is key: A 2016 court ruling allows urban hospitals meeting requirements to reclassify themselves as rural hospitals for certain financial purposes. Changing geographic classification can boost a hospital's Medicare payment and open them up to more residency funding."

The awards show how urban hospitals used reclassification to add slot funding. "In the first tranche of new residency slots awarded, about 6% went to geographically rural hospitals, while 42% went to geographically urban hospitals that reclassified as rural, according to NRHA data," Goldman adds. "NRHA wants the law changed so reclassified urban hospitals no longer qualify for the 10% rural residency slot allotment, said Cochran-McClain."

Fixing the rural physician shortage can begin with adding more federal and state funded residency slots

When residency slots increase, the number of
rural physicians can increase. (UICOMP photo)

By any measure, rural America is hurting for physicians, but more broadly, the nation doesn't have enough doctors. While U.S. medical schools have increased their enrollments, hospitals have yet to increase their number of residency slots, reports Brenna Miller of the Lown Institute, a nonpartisan health think tank.

"Medical school enrollment has been consistently growing, but funding for residency slots hasn't caught up. For every medical school graduate looking for a resident position, there have been between 0.8 and 0.85 slots available in recent years. This a problem as states require at least one year of hospital residency as a licensing requirement."

Without intervention, rural physicians will become increasingly scarce. "Rural areas face the brunt of this shortage as urban areas have higher densities of primary care physicians and specialists," Miller writes. "Patients in rural areas tend to be older, poorer, and sicker, especially with chronic conditions. With fewer doctors around, they have to travel further for both preventative and emergency care, putting them at greater risk for poor health outcomes and mortality."

If rural areas want more doctors in the future, there must be fundamental changes to residency funding and slot offerings. Miller explains, "The mismatch between medical school enrollment, residency slots, and the need for physicians in the workforce has resulted in a lose-lose situation where perfectly competent physicians face barriers to working while simultaneously, entire regions of the country are without sufficient access to physicians."

Some changes need to begin at the federal level. Residency slots are primarily funded by the Centers for Medicare & Medicaid Services, meaning that "they need action by the federal government for expansion. This also means that no significant action had been taken for over 20 years (Congress had actually capped the number of residents) until the Covid-19 relief bill was passed," Miller reports. "The  bill opened the door for 1,000 new residency slots, 10% of which must be in rural areas. Another similar bill has been introduced in Congress that would allocate funding for an additional 2,000 residency slots every year for seven years starting in 2025."

State funding is an additional option. Miller reports, "The majority of doctors stay in the states where they completed their residency. Both California and Texas – where the shortage is predicted to be the worst – approved multimillion-dollar expansions in funding, resulting in increased retention of physicians in underserved, local areas."

U.S. physician shortages expected to increase dramatically as older doctors retire or quit because of heavy workloads

Lack of doctors will mean a sicker population.
(Photo by J.C. Gellidon, Unsplash)

U.S. physician shortages are expected to increase substantially as aging doctors retire or extreme workloads push them out. "As the aging population's need for care grows, retirement and burnout are both driving swaths of health care workers out of the field, fueling a crisis that shows no signs of stopping,"  reports Alejandra O'Connell-Domenech of The Hill. "The country is expected to suffer a shortage of up to 124,000 physicians in the next 12 years, according to a 2019 report from the Association of American Medical Colleges." American Medical Association President Jesse Ehrenfeld told O'Connell-Domenech: "When people don't have access to routine primary care and preventative services [due to no physician access], they live sicker and die younger. . . . These are things that are only going to get worse as we put more pressure on the physician workforce." In many rural areas, the lack of doctors is already a stark reality.

If there aren't enough physicians, those who are working will have to work longer hours with sicker patients, which leads to burnout and more doctors deciding to retire or leave medicine altogether. "A 2022 study found that nearly 63 percent of physicians experienced symptoms of burnout by the end of 2021, representing a 19 percent increase from 2017," O'Connell-Domenech reports. "Another 2022 study determined that one out of five doctors said they were likely to leave their current practice within two years, citing burnout and workload as two major reasons."

The numbers explain another reason for the shortage. "There are about 55.8 million people aged 65 and older in the United States, according to Census Bureau," O'Connell-Domenech explains. "Their numbers are growing and will continue to do so. . . . Almost half of working physicians in the United States are 55 and older, according to the AMA. Thirty-five percent of the physician workforce will reach retirement age within the next five years."

Possible solutions include lessening student loan debt and increasing the number of physicians allowed to train. "The Resident Physician Shortage Reduction Act of 2023 could help by lifting the cap on residency programs," O'Connell-Domenech adds. "The bill. . . would expand the number of Medicare-supported medical residency positions by 14,000 over seven years. . . . Another piece of legislation that could help stem the shortage is the Conrad State 30 and Physician Access Reauthorization Act, according to Ehrenfeld. Under the bill, international doctors could stay in the U.S. after their residency programs as long as they committed to practicing medicine in parts of the country with physician shortages. . . . Easing medical student debt could also potentially increase the amount of doctors willing to work in underserved areas, Ehrenfeld said."

New, lifesaving antibiotics don't make it to patients. Researchers say a different business model is needed.

Antibiotics have played a major role in helping to extend the average life expectancy across the world by fighting infectious diseases. But the companies that develop and produce antibiotics are struggling to make profits on the antibiotics they produce, causing severe problems in efforts to fight newer disease strains and keep patients alive. "The Treasure Called Antibiotics" explains the drugs' impact: "Prior to the beginning of the 20th Century, infectious diseases accounted for high morbidity and mortality worldwide. The average life expectancy at birth was 47 years. . . . The antibiotic era revolutionized the treatment of infectious diseases worldwide, although with much success in developed countries. . . . In the U.S., the average life expectancy at birth rose to 78.8 years."

Stock prices slide on new antibiotic companies.
(Graph by Josh Ulick,WSJ, from Dow Jones data)

But those once powerful drugs are no longer always effective. Antibiotic-resistant bacteria require new antibiotics; however, the companies that create new strains don't make money, reports Dominique Mosbergen of The Wall Street Journal. "The push for antibiotics to fight fast-evolving superbugs is snagging on a broken business model. Six startups have won Food and Drug Administration approval for new antibiotics since 2017. All have filed for bankruptcy, been acquired or are shutting down. About 80% of the 300 scientists who worked at the companies have abandoned antibiotic development, according to Kevin Outterson, executive director of CARB-X, a government-funded group promoting research in the field."


The crux of the problem is the current model for drug company profits, "which counts on companies selling enough of a new treatment or charging a high enough price to reward investors and make a profit — isn't working for antibiotics," Mosbergen explains. "New antibiotics are meant to be used rarely and briefly to defeat the most pernicious infections so bacteria don't develop resistance to them too quickly. Companies have priced them at 100 times as much as the generic antibiotics doctors have prescribed for decades, costing a few dollars per dose. Most have sold poorly."

Infectious disease specialist Dr. John. H. Rex told Mosbergen, "Antibiotics are like fire extinguishers. You really want these drugs available, but you mostly don't want to use them. That's the paradox." Mosbergen reports, "New antibiotics should get support similar to treatments for rare diseases, said Ryan Cirz, a co-founder of Achaogen, which filed for bankruptcy in 2019 less than a year after the FDA approved its drug Zemdri for complicated urinary tract infections. . . . The Orphan Drug Act of 1983 provides subsidies, tax breaks and additional years of market exclusivity to drugmakers that develop treatments for diseases affecting fewer than 200,000 people in the U.S."

"About 13,000 people in the U.S. each year develop a severe type of drug-resistant infection that Achaogen's drug Zemdri was developed to defeat," Mosenberg reports. "Up to half of people hospitalized with such infections die. They are among the more than 35,000 people in the U.S. who die annually from drug-resistant bacterial or fungal infections, a toll that has risen in recent years."

In 2019, the United Kingdom started a "subscription-style model to pay drugmakers for new antibiotics based on their potential public-health value," Mosbergen adds. "U.S. lawmakers have considered similar legislation. Bipartisan bills reintroduced in the House and Senate in April committed $6 billion to purchase new antibiotics to treat drug-resistant infections. They haven't received a vote." Dr. David Hyun, director of the Antibiotic Resistance Project at Pew Charitable Trusts, told Mosbergen: "It sounds like the intent is to save companies, but we're really talking about trying to fix the antibiotic pipeline itself."

Rural doctors have to do it all, from snake bites to meat-stuck-in-throat; video looks at challenges of rural medicine

Amid a national physician shortage, getting a doctor to practice in a rural place has never been more challenging, and as rural hospitals close, the lack of providers is predicted to worsen, reports Hyacinth Empinado of STAT. "In 2023, 65% of rural areas had a shortage of primary care physicians, according to a report published by the Health Resources and Services Administration. More than 15% of Americans — about 46 million — live in rural areas, but only 10% of doctors practice in these communities, many of whom are primary care and family physicians."

Meeting the medical needs of 46 million Americans is a big undertaking. And because there are so few doctors, each has to work harder to tackle vastly different medical illnesses and accidents with limited resources. In this short documentary, STAT explores why the shortage exists and "shows what life is like for a doctor in Kansas who wears many hats and a physician in Illinois pondering retirement."

As rural communities lose physicians, a creative "patchwork" of care can emerge

An OnMed health kiosk uses high tech, remote care.
(Photo by Arielle Zionts, KFF Health News)

Rural patients are more likely to face medical provider shortages, and these communities have to find new ways to provide care. In LaFayette, Alabama, "Terry Vester and her husband, Al, are the only primary care doctors in the town of 2,700 residents, surrounded by farms and other small communities," reports Arielle Zionts of KFF Health News. "The Vesters are in their late 60s and would like to retire soon. Terry Vester wants to spend more time with her grandson and aging parents. But she can't imagine abandoning her patients, some of whom she has cared for since they were born."

Attracting new physicians is challenging for LaFayette, which is not a wealthy town with the amenities many doctors seek. Residents have a median income of $39,077, compared to the state's $59,910. "Black residents — who make up 70% of the population — are much more likely to live in poverty than white residents," Zionts writes. "The Vesters have worked in LaFayette since the early 1980s and saw the local hospital close in 1988. The nearest emergency room is now in another town 20 minutes away along a rolling road. So are the nearest urgent care clinic and pediatrician's office."

With those barriers in mind, town residents who need medical advice have turned to "the city fire department, staffed with full-time firefighters and emergency medics," Zionts reports. "People from LaFayette regularly walk or drive themselves to the fire station to ask for help, said Fire Chief Jim Doody. He added that the station has a makeshift exam area within its small entryway, containing a bench, defibrillator machine, and cabinet filled with medical supplies. . . .This de facto walk-in clinic option isn't available in most other rural areas, where emergency medical services are often run by volunteers who aren't posted at a station all day, Doody said. But he's noticed fewer LaFayette residents relying on the fire department since a new telehealth service arrived in town."

OnMed telehealth kiosk service opened in LaFayette to meet basic medical needs. Patients can head into a computerized booth, press a button and see "a nurse practitioner appear on a large vertical video screen positioned at eye level," Zionts explains. "OnMed patients use an automated blood pressure cuff and other devices to collect their vital signs, and the data is sent to the provider treating them from a distance. Patients can also hold a stethoscope to their chest to transmit the sounds of their heart and lungs. A special camera captures internal temperatures, which can be used to diagnose infections. A hand-held camera lets providers examine problems such as rashes, irritated eyes, and swollen throats. In some states, the stations can dispense medications."

While Vester spoke positively about OnMed services, she feels "It's still important to have doctors in town," Zionts reports. "Vester plans to reach out to Alabama medical schools to let them know she's looking for doctors to take over for her and her husband."

Most people have end-of-life wishes, but don't talk about it; planning for death is less likely in rural areas, study finds

St. David's Foundation graph; click on it to enlarge.

As America ages, more families face end-of-life decisions, and rural Americans are less likely to have their wishes known or followed by family members, reports Liz Carey of The Daily Yonder. "A new study found that while most people have end-of-life wishes, only a little over a third of them actually get them fulfilled. That is even more true with rural residents, researchers said."

Researchers from St. David's Foundation in Texas found that when it comes to end-of-life care, most Texans want to die at home (76%) and not be a burden to their families (77%). "But only one in three people surveyed said their loved one's wishes were honored," Carey writes. "Of those who are least likely to have their end-of-life wishes followed are rural residents, the study found. . . . Only 37% of the survey respondents said their loved ones died at home. Close to half of them (47%) said their loved one faced challenges related to their care – from problems with insurance coverage to facing cultural or language barriers."

Honoring a person's wishes begins with knowing what they are. Andrew Levack, senior program officer with St. David's Foundation, told Carey: "One of the interesting things the study found was how few conversations respondents had with their doctors around plans for end of life. I think people have an idea of what they would like, but it takes some active planning and advocacy to make that happen."

Study researchers noted a common thread of disconnection across the state -- people have end-of-life care desires, but don't voice them. "Most Texans, even older adults, are unprepared for decisions about end-of-life care. The vast majority believe it is important to have their wishes in writing, yet over half have not done so. Similarly, many say they would like to discuss end-of-life planning with their health care provider if they were faced with a serious illness, yet only 17% have had a provider initiate a conversation about it."

Geographical isolation and a lack of health care access make rural populations more likely to not have end-of-life plans or discussions. Dr. Kate Tindell, medical director for Austin Palliative Care and Hospice, told Carey: "People have really disjointed health care now. We've sort of lost that sense that there is a captain of the medical ship who is aware of all the moving parts and is giving the patient that guidance. I think that really causes people to not have the kind of relationship that would allow them to have that kind of conversation (about end-of-life wishes) the way they would if they had seen the same provider every single time for 10 years."

Rural help for expecting and postpartum moms is coming from someone new with a 'baby phone'

Paramedic Darren Forman sees a Project Swaddle
patient in her home. (Photo via RHI Hub)

Rural women, infants and toddlers often need special supports that are difficult to get in more remote areas. The fire department in an Indiana town of 16,000 is filling that need with a "baby phone," reports Gretel Kauffman of the Rural Health Information Hub. "Through Project Swaddle, a home visitation program in which a community paramedic brings wrap-around care to pregnant and postpartum patients, the Crawfordsville Fire Department has provided education, support, and medical care to more than 200 women. . . . Bringing resources and support to women experiencing at-risk pregnancies or other social or environmental challenges, the program aims to keep vulnerable patients from falling through the cracks in a maternity-care desert."

Darren Forman is a Project Swaddle paramedic and Kauffman's object example: "When Darren Forman's baby phone rings, he answers." Callers have been "a young mother calling for help on a Friday evening after a domestic dispute. A pregnant 17-year-old girl stopped by law enforcement after a methamphetamine relapse. A woman in need of a listening ear following a miscarriage. Through the baby phone, expectant and new mothers can reach Forman at all hours of the day and night with questions, crises, medical needs, or just to talk."

The need for Project Swaddle arose in 2011, when Crawfordsville's main hospital, Franciscan Health, closed its birthing unit. Five years later, "a community needs assessment revealed a gap in care and resources for mothers and babies in Montgomery County. But the severity of the issue came as a wake-up call for many community members and leaders, including first responders," Kauffman reports. The Crawfordsville city and county leaders moved to find a way to bridge the gap. "They turned to the Crawfordsville Fire Department, which had already begun to launch a home visitation program focused on chronic disease management. With that foundation laid, the department decided to pivot to try something new: shifting the focus of the home visitation program to moms and babies instead."

Wikipedia map, adapted

Kauffman reports, "Since then, Project Swaddle has expanded into a mobile integrated healthcare program offering wrap-around services to pregnant and postpartum women, with a holistic approach that requires coordination between paramedics, physicians, nurses, social workers, and other service providers in the community. Patients can enroll in Project Swaddle as early as the first trimester of their pregnancy and receive care up to 90 days postpartum; the program is in the process of expanding to serve mothers up to one year postpartum." Samantha Swearingen, Project Manager for the Crawfordsville Fire Department, told Kauffman: "We like to say the program is physician-led but patient-centered."

Project Swaddle developers put together a how-to guide with best practices for communities that want to start a similar program. "Swearingen notes that the Crawfordsville Fire Department was fortunate to have already had a relationship with the Franciscan Health Network after partnering with the local hospital for previous programs, making it easier to establish a partnership for Project Swaddle," Kauffman adds. "Having 'passionate, dedicated practitioners' has also 'been huge for us,' Swearingen said. Still, funding has been an ongoing challenge for the program, organizers say. After initial funding through a one-year grant from the Montgomery County Community Foundation and the Indiana Department of Health, the program is primarily funded today by the Franciscan Health Network and the city of Crawfordsville."

Different initials, but education and care are the same; osteopaths, or D.O.s, are filling a rural void with 'their thing'

Kevin De Regnier, an osteopathic physician in Winterset, Iowa,
examines Alice Collins. (KFF Health News photo by Tony Leys)

In rural America, you may be more likely to be treated by a "Doctor of Osteopathic Medicine," or D.O., instead of an M.D., but their schooling and boarding tests are alike," reports Tony Leys of KFF Health News. "Osteopathic physicians go to separate medical schools from medical doctors. . . . Their courses include lessons on how to physically manipulate the body to ease discomfort. But their training is otherwise comparable, leaders in both wings of the profession say. . . . Both types of doctors are licensed to practice the full range of medicine, and many patients would find little difference between them aside from the initials listed after their names."

Although currently not as common, D.O. numbers are increasing, especially in rural areas, partly because new osteopathic medical schools have located in places like Pikeville, Ky., and Harrogate, Tenn. "School leaders say their locations and teaching methods help explain why many graduates wind up filling primary care jobs in smaller towns," Leys reports. "U.S. News & World Report ranks medical schools based on the percentage of graduates working in rural areas. Osteopathic schools hold three of the top four spots on the 2023 edition of that list."

"The very nature of osteopathic training emphasizes primary care. That's kind of their thing," Michael Dill, director of workforce studies at the Association of American Medical Colleges, told Leys.

Leys reports, "Data from the University of Iowa shows osteopathic physicians have been filling rural roles previously filled by medical doctors. The university's Office of Statewide Clinical Education Programs tracks the state's health care workforce, and its staff analyzed the data for KFF Health News. The analysis found that, from 2008 to 2022, the number of D.O.s based outside those urban areas [previously filled by M.D.s] increased by 29%. Because of the shift, D.O.s now make up more than a third of rural Iowa physicians, and that proportion is expected to grow."

From 1990 to 2022, "the number of osteopathic doctors more than quadrupled, from fewer than 25,000 to over 110,000, according to the Federation of State Medical Boards. Over half of D.O.s work in primary care, which includes family medicine, internal medicine, and pediatrics. By contrast, more than two-thirds of M.D.s work in other medical specialties," Leys reports.

First tribally affiliated medical school in the U.S. creates a life-changing partnership for under-served communities

Medical students stand outside the College of Osteopathic Medicine
at the Cherokee Nation. (Photo by Oklahoma State University)

Nearly a decade in the making, Oklahoma State University and the Cherokee Nation have opened the country’s first tribally affiliated medical school. "The 84,000 square foot facility in Tahlequah officially opened its doors in early 2021, following half a year of virtual classes for the college’s first cohort of students," reports Gretel Kauffman for Rural Health Information Hub. "The facility itself was paid for by the Cherokee Nation, while OSU staffed the college and provided the educational technology. The school had been nearly a decade in the making, with conversations between OSU and the Cherokee Nation starting in 2012."

Amid a national physician shortage, "Oklahoma has one of the most severe doctor shortages in the nation, ranking 48th for number of active physicians per capita in 2022," Kauffman writes, "In rural parts of the state, it isn’t uncommon for a county to have one primary care provider, said Natasha Bray, dean of the College of Osteopathic Medicine at the Cherokee Nation. While telehealth has proven to be a helpful tool for some communities, it isn’t a reliable alternative for patients who lack access to high-speed internet, Bray said — and isn’t a direct substitute for in-person care."

Bray told Kauffman, "All people deserve a health-care provider who’s going to be able to be their partner and be present with them. The development of that relationship is so critical to building trust and improving care in our rural communities." Physicians who are "homegrown" are more likely to embrace rural life. Bray said, "They understand all that is amazing about living in a rural community, and they understand what the challenges are. They’re able to successfully build a practice and care for their community because they have an understanding of what’s involved in it.”

Only one in five of the students are Native American, Kauffman reports: "Roughly half hail from rural Oklahoma. Those percentages are in stark contrast to other medical schools across the U.S., where less than 5 percent of students come from rural backgrounds; that percentage drops to less than 0.5 percent for rural students from under-represented racial or ethnic minority groups. Meanwhile, American Indian and Alaska Native students account for less than 1 percent of medical students nationwide."

Bray explained the spirit of the school to Kaufmann: “When we look at success in medical education, one of the important components for avoiding burnout is your sense of belonging within a community. Having people who share your mission, your values, and your goals is extremely important — and that translates not only to individual well-being, but also to academic success.” Cassie McCoy, a second-year student, told Kauffman, “There is just this natural sense of family, and I think OSU does a really good job of promoting that and creating a culture where we can ask each other for help. You just feel that community, that sense of pride and belonging.”

Officials, advocates push more rural health-care providers to prescribe Suboxone (buprenorphine) for drug addiction

Bonnie Purk, left, meets with nurse practitioner Andrea Storjohann at the
Primary Health Care clinic in Marshalltown, Iowa. (Photo by Tony Leys, KHN)

More than 150 people a day die of overdoses related to synthetic opioids such as fentanyl, and disproportionate share of the dead will be from rural areas, according to the Centers for Disease Control and Prevention. Given the magnitude of loss and the prevalence of fentanyl in most illicit drugs, more rural medical providers are prescribing buprenorphine for patients struggling to end their addictions, and treatment advocates are pushing them to do more, Tony Leys reports for Kaiser Health News: "The number of U.S. health care providers certified to prescribe buprenorphine more than doubled in the past four years. Treatment advocates hope to see that trend continue."

Buprenorphine, best known by the brand Suboxone, "does not cause the same kind of high as other opioid drugs do, but it can prevent the debilitating withdrawal effects experienced with those drugs," Leys notes. "Without that help, many people relapse into risky drug use.

Such “maintenance treatment” has been done mainly with methadone, but it "is tightly regulated, due to concerns that it can be abused," Leys explains. "Only specialized clinics offer methadone maintenance treatment, and most of them are in cities. Many patients starting methadone treatment are required to travel daily to the clinics, where staffers watch them swallow their medicine."

Federal approval of Suboxone in 2002 helped smaller towns, but physicians have been slow to get certified to prescribe it. Recently, "Federal regulators have made it easier for doctors, nurse practitioners, and physician assistants to become certified," and "have encouraged more front-line health care professionals to prescribe Suboxone and other medications containing buprenorphine." Congress could relax the rules even further in must-pass legislation next week.

The spread of fentanyl has complicated the effort to expand the treatment. Patients "can suffer severe withdrawal symptoms when they begin taking buprenorphine, so health practitioners must be careful when starting the treatment," Leys reports. "In Iowa, officials designated $3.8 million from the state’s initial share of opioid lawsuit settlement money for a University of Iowa program that helps health care providers understand how to use the medications.

Andrea Storjohann, a nurse practitioner in Marshalltown, Iowa, a town of 27,000, works in a repurposed grocery building, with "no signs designating it as a place for people to seek treatment for drug addiction, which is how Storjohann wants it," Leys writes. Until recently, “We were kind of a unicorn in this part of the state, but that is changing,” Storjohann told Leys.

Still, treatment may be hard to find. The public database of providers certified to prescribe buprenorphine treatment "lists only providers who agree to include their names," Leys reports. "Many do not do so. In Iowa, only about a third of providers with the certification have agreed to be listed on the public registry, according to the Iowa Department of Health and Human Services."