Rural America makes up between 15-20% of the U.S population and faces inequities that result in worse healthcare than that of urban, and suburban residents. Even though overall mortality rates are declining nationwide rural areas have been much slower. According to the CDC, heart disease, cancer, chronic lower respiratory disease, and stroke are higher in rural communities. Rural areas tend to have higher infant mortality rates, and greater rates of mental, behavioral, and developmental disorders.  The ethical issue here is equity for rural America, since rural-Americans lack access to healthcare, and suffer more diseases compared to patients living in urban cities

According to the AAMC, there are about 55.1 primary care physicians per 100,000 residents in rural areas compared to 79.3 per 100,000 in urban areas, the numbers are far worse for specialty the National Rural Health Association Reports about 30 specialist per 100,000 in rural areas compared to 263 per 100,000 in urban residents. The AAPA found that 16% of clinically practicing PAs were in rural areas compared to 84% in urban country. With the large discrepancy between practicing clinicians in the rural and urban counties it is quite difficult for those in rural areas to seek treatment. This is compounded by the fact payments tender to favor specialist, and subspecialist over primary care, and consequently rural hospitals hire more specialist, and at times can discontinue critical services. A study from University of Minnesota School of Public Health found that 54% of rural counties did not have hospitals with obstetric services, in certain parts of the country some must travel 200 miles for OB/GYN service. Studies have shown that there is a physician shortage, however the shortage is in rural area as physicians, and PA tend to work in urban cities, and are likely to specialize working in primary care.

Rural communities share common challenges; however, residents are racially, and ethically varied, and they have distinct health inequities. For example, African Americans have a higher rate of cancer morbidity, and mortality when compared to other rural residents. The North Carolina Rural Health Research Program reports at least 80 rural hospitals across 26 states have closed since 2010, and many are in communities that have significant African American, and Hispanic populations. In Alabama a hospital where the residents are 72% African American has closed, and the nearest hospital is 50 minutes away.

The PA profession was founded to address the disparity in healthcare delivered in rural America, but it has failed to address that issue. On the ethical principles of equity and justice as healthcare professionals we are failing to deliver quality care to an underserved population. A 2018 study from NCCPA compared PA’s in primary care vs Non-Primary care, and for all 50 states there were more PAs working in Non-Primary care. In addition, states with large rural areas such as, Wyoming, Idaho, North Dakota, Mississippi have less than 300 PAs working in the state with Mississippi only have 173 PAs, and 76% of them work in non-primary care. These statics are a telling story, about how as a profession, we are failing an extremely underserved community. The AAPA defines justices as “patients in similar circumstances should receive similar care. Also applies to norms for the fair distribution of resources, risks, and costs”. As great as the statement sounds, there is huge disparity between justice to urban areas, and rural areas.

Fixing the healthcare disparity in rural areas will not be an easy task. However, there are solutions. Quillen College of Medicine was founded to address of rural populations. Quillen, has it where students receive rural exposure during training through rural immersion experience, and learning. Also, Quillen’s curriculum is built around students’ cultural sensitivity to rural patients. The Health Resources and Services Administration has Primary Care Training and Enhancement – Physician Assistant Rural Training (PCTE-PAR) program, where schools can qualify for a grant if they provide PA students with longitudinal clinical training experiences for a minimum of 8 weeks in primary care in rural areas, educate and train PAs to identify and address health inequities, and if the school develops, and strengths partnership between academia, and primary care systems such as  National Rural Health Association, and community organization that implement interprofessional rural clinical training experiences for primary care PA students. In addition, the Health Resources and Services Administration has student loan forgiveness programs where if a PA, doctor or a nurse commits for three years to work in a rural area they will have their loans forgiven. Through these financial incentives, and schools building curriculum around rural healthcare we will once close the gap in disparity for rural areas.