Although fourteen percent of the U.S. population lives in rural areas, only ten percent of primary care physicians practice medicine there; populations in areas with physician shortages have measurably worse health outcomes. We analyze the effects of incentive programs intended to eliminate physician shortages. Using a differences-in-differences approach, we estimate that student loan forgiveness programs cause an increase of three physicians per rural county. We then estimate a model of physician location decisions and find that physicians are unresponsive to differences in compensation and prefer to live in their home state. Consequently, current programs are too small to eliminate shortages.

Two sociologists reveal how small towns in Middle America are exporting their most precious resource—young people—and share what can be done to save these dwindling communities In 2001, with funding from the MacArthur Foundation, sociologists Patrick J. Carr and Maria J. Kefalas moved to Iowa to understand the rural brain drain and the exodus of young people from America’s countryside. They met and followed working-class “stayers”; ambitious and college-bound “achievers”; “seekers,” who head off to war to see what the world beyond offers; and “returners,” who eventually circle back to their hometowns. What surprised them most was that adults in the community were playing a pivotal part in the town’s decline by pushing the best and brightest young people to leave. In a timely, new afterword, Carr and Kefalas address the question “so what can be done to save our communities?” They profile the efforts of dedicated community leaders actively resisting the hollowing out of Middle America. These individuals have creatively engaged small town youth—stayers and returners, seekers and achievers—and have implemented a variety of programs to combat the rural brain drain. These stories of civic engagement will certainly inspire and encourage readers struggling to defend their communities.

The United States is facing a major healthcare shortage in rural areas. One-fifth of the U.S. population lives in a rural area and over 75 percent of those are deemed to be in a healthcare professional shortage (McEllistrem-Evenson, 2011). More physicians in particular are needed in rural areas. Currently, the primary needs of the rural areas are family medicine and primary care physicians. However, less medical school students are interested in family medicine than ever before. Rural physicians face additional challenges such that they see more patients than urban physicians, work more hours, and are on-call more often. Despite these challenges, rural physicians receive approximately the same compensation as physicians working in urban areas (Hart, Lishner, & Rosenblatt, 2005). The patient population in that the rural population tends to be more ill, have worse access to healthcare, are more likely to be in poverty, and typically pursue less education than those living in urban areas (American Academy of Family Physicians, 2015). If these issues go unaddressed, rural people will continue to struggle to receive the adequate healthcare that they deserve and need.

Our market-based, profit-driven health care system in the United States has put necessary care increasingly beyond the reach of ordinary Americans. Primary health care, the fundamental foundation of all high-performing health care systems in the world, is a critical but ignored casualty of the current system. Unfortunately, primary care is often poorly understood, even within the health professions. This book describes what has become a crisis in primary care, defines its central role, analyzes the reasons for its decline, and assesses its impacts on patients and families. A constructive approach is presented to rebuild and transform U.S. primary care with the urgent goal to address the nation's problems of access, cost, quality and equity of health care for all Americans.