Addressing Provider Shortages
in Rural & Underserved Alabama
An ACES Policy Spotlight on Rural and Underserved Alabama Healthcare Initiatives
The Efforts
A previous ACES evaluation revealed many efforts in Alabama that attempt to address provider shortages in areas of need. In just the last two years, Alabama state funds have invested in numerous programs designed to recruit and retain medical professionals in rural and underserved parts of the state. Unfortunately, few of those programs were designed with outcome monitoring in place and, in practice, serve more as a rural service encouragement rather than recruitment and retention programs. Still others have yet to become operational and do not have an implementation plan. Therefore, Alabama does not currently, nor are we in the position to, know the comprehensive impact of these programs on intended outcomes.
Alabama Efforts. Alabama efforts target the full spectrum of potential medical professionals from high school students to recruitments and supports for already practicing physicians. Programs aimed at students in high school through post-graduate education are rural recruiting fairs, academic scholars’ tracks, and networking opportunities at state conferences. These efforts attempt to find individuals that are willing to practice in rural communities. There are more specific efforts targeted at those individuals originating in rural areas to receive medical training and return to a rural community.
Beyond recruiting potential medical students, programs targeted at students in medical programs exist in many forms. As previously highlighted in ACES Medical Professional Scholarship and Loan Forgiveness Service Assessment, the state provides funding to graduate and post-graduate medical professionals to increase medical providers in identified areas of need. Additionally, Alabama’s universities and schools of medicine operate programs designed to address the state’s healthcare shortages. Although these programs do not necessarily require rural service, they do track and monitor outcomes. Some programs include:
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- UAB School of Medicine Huntsville Rural Pre-Med Program
- UA and UAB School of Medicine Tuscaloosa, Rural Medical Scholars Program
- Auburn and UAB School of Medicine Huntsville, Rural Medicine Program
- UAB Family Medicine Faculty Development Fellowship
- UA Behavioral Medicine Fellowship
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Table 1: List of FY21 State-funded efforts
| State Effort | FY21 Funding |
| Medical Professional Scholarships & Loans (Dental, Medical, Nursing, Optometric) | $4,351,180 |
| Family Practice Rural Health Board [1] | $2,679,502 |
| Rural Alabama Teaching Health Center | $385,000 |
| Rural Hospitals Resource Center | $1,250,000 |
| Rural Health Care Management Pilot Program | $600,000 |
| Alabama Rural Medical Service Award | $2,000,000 |
| Total | $11,265,682 |
| [1] For a complete list of the Alabama Family Practice Rural Health Board supported programs for FY19 – 21, see below. | |
Alabama Rural Medical Service Award
Between FY21 and FY22 appropriations, Alabama dedicated a total of $4,000,000 to the Alabama Department of Public Health to create and operate the Alabama Rural Medical Service Award for the recruitment of practicing physicians to rural and underserved parts of the state. While this program is not yet operational, it represents nearly 10% of the direct state dollars invested in healthcare shortage areas. Once operational, physicians and nurse practitioners will be eligible to receive up to $50,000 a year for three years for practicing in a designated area of need.
Federal Efforts and Opportunities. Currently, federal grant efforts to address rural and underserved needs are largely utilized by state universities. There are at least twenty programs in the state with a rural/underserved focus that received Health Resources and Services Administration (HRSA) grant funding in FY21, totaling at least $20,769,200. But there are also opportunities to supplement existing efforts with upcoming grant dollars. While six HRSA program categories have upcoming grant opportunities which have not been released in their entirety, Alabama can begin preparing entities able and willing to apply for these grant opportunities. See below for a list of the upcoming opportunities and the FY21 federally funded efforts.
There are also opportunities for healthcare providers to receive scholarships and student loan repayments directly from federal agencies in exchange for service in approved sites located in underserved areas. For a comparison of these programs, see Table 2 below.
Table 2: Comparison of National Health Service Corps (NHSC) Loan Repayment Programs
| NHSC Program | Maximum Award | Service Commitment | Part-time Service Available |
| Loan Repayment | $50,000 | 2 years | Yes |
| Substance Use Disorder Workforce Loan Repayment | $75,000 | 3 years | Yes |
| Rural Community Loan Repayment | $100,000 | 3 years | Yes |
Figure 1: Of the 373 J-1 physicians with current Alabama addresses, 167 (44.7%) are located in three counties – Jefferson, Madison, & Mobile.
Another federal program that addresses provider shortages is the J-1 Visa program managed by ADPH. The program is for foreign medical graduates to apply for a two-year waiver to remain in the U.S. while serving in approved areas of need. Alabama has an estimated 90 physicians actively serving that hold J-1 visas.
Through the J-1 Visa program, there are over 500 physicians that are currently licensed to practice in Alabama. With 373 of those physicians still maintaining Alabama addresses, there is some evidence that the J-1 Visa program assists in reducing provider shortages in Alabama through rural service commitments up to and beyond five years.
Efforts in Neighboring States. A review of neighboring state efforts to address rural and underserved issues found that Medicaid expansion, physician tax credits, and preceptorship tax credits are leading conversations. Of the neighboring states reviewed,[1] only Kentucky and Louisiana have expanded Medicaid, and Alabama is one of only three states – along with Georgia and Louisiana – that provide a rural physician income tax credit. While none of the other states offer physician tax credits, Kentucky and South Carolina have joined Georgia as the states incentivizing physician and other medical provider preceptor income tax credits of varying degrees.
Clinical training in the health professions relies on an adequate supply of preceptors.[i] A preceptor is a licensed provider that voluntarily supervises and instructs students during the clinical components of training. While the Family Practice Rural Health Board recently approved a proposal to begin awarding physician preceptor incentives, the program is only entering the design phase. The $500 monthly stipend for rural family physician preceptors at University of South Alabama and University of Alabama School of Medicine campuses is a renewed retention effort of the Board to encourage preceptors to continue mentorship with those campuses. The Alabama College of Osteopathic Medicine pays $1,000 monthly stipends to preceptor physicians and has since 2015.[ii]
Some states and organizations have conducted needs analysis that include workforce distribution and residency/preceptorship availability which can assist in understanding state needs to appropriately target programs and incentives and address barriers.[iii] Currently, only six states have passed legislation endorsing preceptor tax credits.[2] While Alabama has both paid and volunteer physician preceptors, similar needs analysis could provide a comprehensive understanding of Alabama’s preceptor needs, distribution, and barriers to success.
[1] Florida, Georgia, Kentucky, Louisiana, Mississippi, South Carolina, and Tennessee
[2] Colorado, Georgia, Hawaii, Kentucky, Maryland, South Carolina
Public-Private Partnership
Starting in 2016, to provide primary care access for underserved areas in Alabama, Blue Cross Blue Shield of Alabama agreed to provide $11 million in varying scholarship amounts to 3rd and 4th year students attending four medical schools:
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- Alabama College of Osteopathic Medicine
- University of Alabama at Birmingham
- University of South Alabama
- Edward Via College of Osteopathic Medicine
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Upon accepting the scholarship, students agree to practice primary care in an underserved area for three years after completing residency. To date, there have been 109 individuals that received the award totaling $7.4 million. Sixty students have graduated and an additional 28 students are on track to graduate in 2022. Blue Cross Blue Shield of Alabama utilizes the HPSA service area maps provided by ADPH to determine eligible service areas where students must agree to serve for three years following residency.
Alabama’s medical provider shortage mimics that of the nation, to some extent. As of 2019, about 1,135,428 Alabama residents (23%) live in rural areas.[iv] Only 12.8% of the state’s primary care physicians practice in rural Alabama.[v] In order to ensure that the efforts of these programs are coordinated and effective, there is a need for better reporting of performance metrics and outcome monitoring across the board. These metrics, combined with a thorough needs analysis, could change the impact of Alabama’s efforts on the healthcare shortage in rural and underserved parts of the state.
Federally Funded Efforts
| Receiving Institution | Local Program Title | FY21 Funding | Grant Cycle Years |
| ADPH | State Office of Rural Health | $230,000 | 2021 – 2024 |
| State Primary Care Office | $174,057 | 2019 – 2024 | |
| Cahaba Medical Care Foundation | Closing the Gap in the Primary Care Workforce Shortage | $2,617,560 | 2020 – 2021 |
| Expanding Access to Care in Underserved Rural and Urban Alabama through Enhanced Nurse Practitioner Training (ENPacT) | $544,323 | 2019 – 2023 | |
| Residency Training in Primary Care in rural underserved Alabama | $500,000 | 2021 | |
| Children’s Hospital of Alabama | Graduate Medical Education | $3,269,285 | 2020 – 2021 |
| Samford University | Nurse Anesthetist Traineeships | $36,811 | 2021 – 2022 |
| Building a Better Future | $907,205 | 2019 – 2023 | |
| Spring Hill College | Scholarships for Disadvantaged BSN Students at Spring Hill College | $623,816 | 2020 – 2025 |
| Tuskegee University | Center of Excellence in Veterinary Medical and Public Health Education: A One Health Perspective (TU COE) | $2,891,266 | 2018 – 2023 |
| USA | Medical Student Education | $1,030,561 | 2019 – 2023 |
| Advanced Nursing Education Nurse Practitioner Residency Program Track 1 | $541,398 | 2019 – 2023 | |
| Graduate Medical Education | $1,970,905 | 2020 – 2021 | |
| Partnering to Improve Maternal Outcomes | $599,975 | 2021 – 2026 | |
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UAB
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The Comprehensive Urban Underserved and Rural Experience (CU2 RE) Program for the Primary Care Physician Shortage in Alabama | $1,750,000 | 2019 – 2023 |
| Nurse Anesthetist Traineeships | $84,257 | 2020 – 2023 | |
| Bridging the Gap II: Behavioral Health Integration for Vulnerable Populations in Birmingham | $495,681 | 2020 – 2021 | |
| Building a Resilient Primary Care Registered Nurse Workforce for Chronic Disease Prevention and Control in Alabama | $700,000 | 2018 – 2022 | |
| Training Future Dentists to Care for Alabama’s Underserved Children from 0-5 Years of AGE | $244,244 | 2017 – 2022 | |
| A PA Training Enhancement Initiative from the University of Alabama at Birmingham | $298,452 | 2021 – 2026 | |
| Advanced Nursing Education Workforce | $677,920 | 2019 – 2023 | |
| University of West Alabama | Educating Alabama Rural Nurses (Project EARN) | $581,484 | 2020 – 2025 |
| TOTAL | $20,769,200 |
Upcoming Opportunties
One example of an upcoming opportunity is HRSA’s State Loan Repayment Program. The purpose of this grant program is to assist states in operating their own state educational loan repayment programs for primary care providers working in Health Professional Shortage Areas within their state. There are 43 states, districts, and territories participating in HRSA’s State Loan Repayment Program. Alabama has not been a participant since 2011.
Alabama terminated the previously approved 2011 federal grant award in part due to the state match requirement and competing opportunities without a state match requirement. Though the upcoming funding amount is unknown, the 2018 grant application had awards ranging from $80,000 to $1,000,000 per year.
The American Rescue Plan provided increased funding to HRSA for various programs that are extending new grant opportunities soon. While some grants have previously existed, the programs may have new features or benefits. Eligible entities will be able to apply for program funding upon the announcement of the official notice of funding opportunities. In total, there are twenty-nine upcoming opportunities across seven healthcare areas to assist in addressing rural and underserved areas. The list below includes programs that Alabama did not receive grant funding for in FY21.
(Click on any of the headers below to learn more about these opportunities)
Behavioral / Mental Health
- Behavioral Health Workforce Development Technical Assistance and Evaluation
- Behavioral Health Workforce Education and Training
- Graduate Psychology Education
- Opioid Workforce Expansion for Professionals and Paraprofessionals
- Provider Resiliency Workforce Training
Health Careers
- Area Health Education Centers
- The National HCOP Academies
Loan Repayment
- State Loan Repayment Program
Public Health
- Public Health Training Centers
Medicine
- Preventative Medicine Residency
- Primary Care Training and Enhancement
- Teaching Health Center Graduate Medical Education
- Rural Residency Planning and Development
- Addiction Medicine Fellowship
- Ruth L. Kirschstein National Research Service Award Institutional Research Training
- Integrated Substance Use Disorder Training
Oral Health
- Dental Faculty Loan Repayment
- Oral Health Workforce Activities
- Postdoctoral Training in General, Pediatric, and Public Health Dentistry
- Primary Care Dental Faculty Development Program
Nursing
- Nurse Faculty Loan
- Nursing Workforce Diversity
Alabama Family Practice Rural Health Board 2019 – 2021 Programs
- Alabama Academy of Family Physicians Fall Forum
- Alabama Academy of Family Physicians Residency Booths
- Auburn Rural Health Scholars Program
- Cahaba Family Medicine Residency Time Away
- Clerkships for Medical Students
- Physicians’ Alabama Opportunity Fair
- Scholarships for Alabama Academy of Family Physicians Student Meeting
- Tuskegee AHEC Health College Connection
- UASOM/Tuscaloosa Behavioral Medicine Fellowship
- UASOM/Tuscaloosa Obstetrical Fellowships
- UASOM/Tuscaloosa Rural Medical Scholars Program
- UASOM Rural Rotations for Family Medicine Residents
- UAB Faculty Development Fellowship
- UAB Longitudinal Curriculum Program
- UAB/Selma Family Medicine Residency and UAB/Montgomery Family Medicine Residency SonoSim Ultrasound Projects
- UAB/Selma Family Medicine Residency Hospitalist Fellowship
- UASOM/Huntsville Integrated Residency Program
- UASOM/Huntsville Rural Health Program
- UASOM/Huntsville Rural Pre-Med Internship
- USA Family Medicine Residency Curriculum
- USA Rural Student Curriculum
NEW 2021 Grants include:
- College of Community Health Sciences Colposcopy Training
- Preceptor Stipends
- UAB Project Extension of Community Healthcare Outcomes (ECHO)
Resources and Citations
[i] Enhancing Community Based Clinical Training Sites: Challenges and Opportunities. 2018. 16th Annual Report to the Secretary of Health and Human Services: https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/community-based-linkages/reports/sixteenth-2018.pdf
[ii] https://libguides.acom.edu/preceptors/benefits
[iii] https://www.scdhhs.gov/sites/default/files/GME Advisory Group Report January 2014 final.pdf
Supply and challenges of Primary Care NPs and PAs. 2015. Georgia Mini Summit Results. https://www.augusta.edu/ahec/documents/korn-summit15.pdf
Status Report of the Alabama Primary Care Physician Workforce. 2019. The Office for Family Health Education & Research, UAB Huntsville Regional Medical Campus. [PDF]
Recruiting & Maintaining U.S. Clinical Training Sites. 2013. https://www.aamc.org/media/10921/download
[iv] Rural Health Information Hub, 2019. https://www.ruralhealthinfo.org/states/alabama#:~:text=Alabama%20covers%2050%2C744%20square%20miles,areas%20(USDA%2DERS).
[v] Office of Family Health, Education & Research UAB School of Medicine Huntsville Regional Medical Campus. 2021. Alabama Board of Medical Scholarship Awards Evaluation.