Geographic Location of the Population

1. Population Projections and Regional Growth Patterns
2. Evolving Trends in Urbanization
3. Urban Demography and the Effects on Physician Locations

Trends in geographic location of the population that have important implications for the future health care workforce include the following. First, there is substantial variation in population growth and other factors that affect the supply of and demand for health professionals. This phenomenon highlights the importance of models that can forecast at the State and local level.

Second, a significant proportion of the population will continue to reside in rural areas and have less access to health care services than the population residing in urban areas.

Third, some urban areas will continue to have a high concentration of minorities. These areas are often characterized as having fewer economic resources per capita, greater health care needs, and less access to health care services than surrounding areas.

4.1 Population Projections and Regional Growth Patterns

According to the U.S. Census Bureau (Campbell, 1997), all regions of the country will grow over the next 25 years, with the West and the South growing at the fastest rate (Exhibit 4.1). As the population continues to rapidly grow in these regions, the demands for health care will also increase.

Exhibit 4.1 Population Projections by Region

The uneven regional growth of the population has both short-term and long-term ramifications for the health workforce. Regions of the country that experience rapid growth in population could experience temporary shortages of some health professionals, such as physicians, who might be less mobile than the population at large. Efforts by some localities to recruit specific growth industries-e.g., high-tech industries-without a balanced approach to recruit health professionals could cause a short-term strain on the local health care infrastructure. Areas of the United States that are already experiencing physician shortages and that are high-growth areas might see more severe short-term inadequacies in the health workforce. For example, the Census Bureau estimates that Texas will be one of the fastest growing States over the next 20 years. However, according to the Bureau of Primary Health Care, Texas currently has one of the highest number of physician shortage areas in the country, understandable in view of its size. Not only does this trend appear in Texas, but many smaller southern States also face a combination of high growth and a large number of shortage areas.

Regional differences in physicians per population and nurses per population do not necessarily reflect inadequacies in the health care workforce. As discussed previously, demand for health care services is highly correlated with the age distribution of the population, and there is substantial geographic variation in the age distribution of the population. For example, the proportion of the population age 65 and older is much greater in Florida (18), West Virginia (17) and North Dakota (15) than it is in Alaska (5), Utah (8) and Colorado (9).

In addition, there exists substantial variation in other determinants of demand for health care services such as the characteristics of the health care operating environment, economic conditions, and lifestyle. Douglass (1995) projected the future supply of family physicians on a State-by-State basis and found substantial regional variation in physician supply and needs. One implication of the uneven population growth and geographic variation in the determinants of supply and demand is the need to develop forecasting models that can forecast at the State or sub-State level.

The NDM forecasts demand for nurses at the State level. Preliminary demand forecasts compared to current and future supply forecasts show substantial variation across States in the adequacy of the nurse workforce-both now and in the future (Dall and Hogan, 2002).

4.2 Evolving Trends in Urbanization

Although the proportion of the U.S. population living in metropolitan areas will continue to grow, a large proportion of the population will continue to live in rural areas. A substantial body of literature describes the inadequacies of the physician workforce in rural areas, and over 65 of the Health Professional Shortage Areas (HPSAs) are in rural areas.

Between 1990 and 2000, the population in metropolitan areas increased by nearly 14 percent, whereas the population in non-metropolitan areas grew by only 10 percent (Exhibit 4.2). One reason for this phenomenon is a matter of classifications: geographic regions formerly designated as rural areas are becoming more metropolitan and were re-designated as metropolitan areas. Another reason is immigration: immigrants disproportionately settle in metropolitan areas. A third reason is migration from rural to urban areas, although this effect has been small. The Census Bureau (March 2001) reports that net migration out of rural areas totaled only 137,000 between 1998 and 2000.

The "metropolitanization" of the country could help alleviate the problems of an inadequate supply of physicians in some rural locations as the population in these areas increases above the threshold required to support a more comprehensive health workforce.

Exhibit 4.2 Population Growth by Metropolitan Status and Size

Substantial proportion of the population will continue to reside in rural areas during the foreseeable future. When modeling the supply of health professionals in rural and underserved areas, analysts might consider the following obstacles to increasing physician supply in these shortage areas, as reported in the literature.

• Connor, Hillson and Krawelski (1995) suggest that physicians locate in areas with other physicians in order to benefit from the professional synergism that develops when there is an established population of physicians. Similarly, Brasure et al. (1999) found a general aversion to rural practice may exist among urban professionals, but there is less resistance to enter an underserved market once at least one health provider has settled there. Efforts to model the supply of physicians in underserved areas might identify "forerunner" specialties and analyze patterns of physician location.
• Olchanski et al. (1998) found that the average age of physicians in rural areas of Virginia is increasing, raising concerns that physician shortages in these areas will be exacerbated when these physicians retire. Furthermore, he speculates that this phenomenon could be applicable to other parts of rural America.
• Rabinowitz et al. (1999), in a study of rural physicians in Pennsylvania, found that one of the most critical factors in determining whether a physician will practice in a rural environment is the extent of the physician's rural background. Models of physician supply might incorporate an urban/rural dimension that takes into account the propensity of physicians to practice in physician shortage areas based on the background and demographic characteristics of medical students and the existing physician workforce.

A disincentive to physicians choosing to practice in rural settings is lower earnings potential. For heavily-indebted physicians exiting medical school, practicing in suburban areas where there is greater economic activity can be more enticing than practicing in a rural area.

Government and private organizations have implemented various programs and grants to encourage physicians to practice in underserved, rural areas. For example, the State of Illinois, along with the University of Illinois College of Medicine at Rockford, has implemented a program designed to improve the supply of physicians to these areas. According to Stearns et al. (2000), this program has been reasonably successful, with 69 percent of the graduates choosing to enter rural practices. Efforts to model physician supply might incorporate estimates of the impact of programs that try to influence where physicians will practice. Similarly, some States are offering grants to people in nursing programs who agree to work in rural or underserved areas for a specific length of time following graduation.

Some researchers have argued that international medical graduates (IMGs) can be used to augment the physician workforce in underserved areas. Mick et al. (2000, 1999) have shown that the IMGs are more likely than U.S. medical graduates to locate in rural areas with high rates of infant mortality, fewer per capita economic resources, a high proportion of minorities, a disproportionate number of elderly, and low physician-to-population ratios. Baer et al. (1999) found that IMGs were also fulfilling an important role in community health centers. These centers tend to be located in physician shortage areas, so these researchers suggest that the role of IMGs is indispensable in the rural setting. As hospitals in rural areas close, the authors assert that community health center clinics are the most effective way for underserved populations to receive the health care they require and that IMGs help fill a 'safety net' role.

Not all researchers agree that IMGs help alleviate physician shortages in underserved areas. A study conducted by Politzer, Cultice, and Meltzer (1998) found that the geographic distribution of physicians has become less even. The study also argued that IMGs, rather than helping to mitigate this trend, had in fact contributed to its severity. The authors state that the majority of IMGs choose not to work in areas with a physician shortage, and that the contributions others note are overstated.

4.3 Urban Demography and the Effects on Physician Locations

Pockets of the population will continue to contain high concentrations of minorities. These pockets, generally located in urban areas, are often characterized by lower average levels of economic resources, greater average health care needs, and less access to health care services. COGME (1998) reports that although there appears to be an oversupply of physicians, most of the oversupply is located in affluent urban and suburban areas. Additionally, specialists are especially prone to locating in more affluent areas. The traditionally poor areas of the city exhibit a unique need, as they are often demographically independent from the more affluent areas in the same region.

One of the most sensitive populations is the immigrant population, especially those with little or no English proficiency. Members of this population tend to locate in areas that traditionally consist of low-income households and are more likely to live in cities than non-metro areas. According to the 2000 census, 5.1 percent of foreigners live in rural areas, compared to 20.7 percent of native-born people. This means that as immigration increases, there may be greater pressure placed on urban community hospitals, which typically serve more non-English speaking people (Gaskin and Hadley, 1999). According to Gaskin and Hadley, these hospitals face a higher level of physician and health care professional shortages, thus degrading the level of care provided to the underserved population. As immigration increases in the near future, this strain placed on the community hospitals may increase.

In addition to the use of IMGs in rural areas, Mick has suggested that they may help relieve shortages in the urban areas as well. According to his study, IMGs tend to locate in less affluent areas within a city and are willing to work for a lower salary. Additionally, as discussed previously, some policy makers advocate increasing the efforts made towards recruiting minorities into the health care professions. They claim that these individuals may be willing to work in shortage areas, as well as being able to overcome some of the language barriers that exist in some of these areas (Trevino 1994, Komarmony et al., 1996).