The Doctor is Out

I wrote this feature about the primary care doctor shortage for the fall 2025 issue of Oregon Business Magazine.

The number of primary care providers in Oregon is flatlining — especially in rural areas. But experts say the problem is curable.

Two years ago Connie Cloyed was living in Corbett when she finally found a primary care physician she liked who was covered by United Healthcare. Cloyed, who is almost 70, had been on Medicare a few years at that point and had changed insurance providers each year because she was unhappy with a lack of transparency on costs and coverage. But this time, she really liked her PCP. She was relieved. 

“Years and years ago, I had cancer, and I was not going to just go to any old doctor,” Cloyed says. 

“The next year, I get this letter that she’s going to the VA, so she no longer exists as a PCP, and there’s not another PCP in my clinic,” Cloyed says. She called the office, and the receptionist said she could see a nurse practitioner or a physician’s assistant. “I don’t mind seeing either one for a specific need…but I don’t want that as my PCP. I want an actual doctor. And there just isn’t anyone.”  

Connie Cloyed at her Netarts home (Photo by Jason Kaplan)

If you haven’t heard, there’s a shortage of primary care doctors in Oregon. As primary care doctors age and retire, it’s become exceedingly hard for patients to find new ones—especially in rural areas. But it’s a challenge even in the Portland metro area. In April The Oregonian/Oregon Live polled 600 Portland-area voters and found that more than half found it harder to get an appointment with a primary care doctor than they did three years ago. This is partly because from 2014 to 2019, there’s been a 13% decline in the total number of primary care clinicians in Oregon, according to the Primary Care Collaborative’s Evidence Report from 2023. And according to the latest data from the U.S. Department of Health and Human Services, almost the entire state is in what it calls a Health Professional Shortage Are (HPSA). 

“Regardless of the source that we look at, we know that the demand for primary care generally exceeds the number of clinicians available to provide it,” says Clare Pierce-Wrobel, the Oregon Health Authority’s Health Policy and Analytics Director. In fact, this is true for many types of health care workers in the state, including dentists, nurses and dermatologists. But primary care doctors in particular increasingly report high burnout rates and dissatisfaction with work-life balance as a reason for going part-time—or taking early retirement. 

Every two years, the Oregon Health Authority publishes a Health Care Workforce Needs Assessment. The latest one shows that Oregon has a total of 9,584 primary care providers (PCPs), for an average ratio of 17 per 10,000 residents. (This number includes both M.D.s and D.O.s; naturopathic doctors; nurse practitioners; and physician associates who work in family medicine, internal medicine, geriatrics, pediatrics and obstetrics/gynecology.) The shortage is worse in rural areas of the state, getting as low as 4.6 PCPs per 10,000 people in counties like Sherman. 

This primary care doctor shortage is not unique to Oregon—it’s happening across the entire U.S. 

Research consistently shows that primary care is the foundation of an effective health care system. Having good access to primary care physicians not only improves patient outcomes, it lowers mortality rates. But for a variety of reasons — partly because we have a fee-for-service system and partly because we’ve underinvested in primary care at the federal and state levels for decades — primary care doctors in the U.S. are in short supply. The U.S. has fewer primary care physicians as a share of its population than almost any other rich country. 

One Ailment, Many Causes 

There are many reasons we lack a sufficient number of primary care doctors in this country. 

First, medical students are less and less likely to go into family medicine because it doesn’t pay as well as specialties like cardiology, dermatology or neurosurgery. When you have looming medical school debt, an annual salary of $587,360 (for cardiology) is more enticing than a salary of $318,959, which is the average family-medicine salary in the U.S. according to the latest figures from Doximity. (This same Doximity report shows that when compensation is adjusted for cost of living, Portland is the city with the 10th worst compensation for any type of doctor in the U.S.) 

Second, policy shifts at the national level have kept the number of residencies in family medicine artificially low. Primary care residencies are important to increasing the number of PCPs in the state because research shows that over half of all family medicine residents end up practicing within 100 miles of their residency.  

In their new book, Abundance, authors Ezra Klein and Derek Thompson point to federal policy failures. “In the early 1980s, a special committee established to review the state of American medicine reported to the U.S. Department of Health and Human Services that the U.S. was on the verge of a massive surplus of doctors,” they write. “Physician groups backed up the finding…. Starting in the 1980s, the government cut its support for medical schools and medical students, and many universities agreed to freeze the number of new studies and stop construction on medical programs.” Between 1980 and 2005, they report, the number of medical school graduates “flatlined.” The policy of “deliberate scarcity,” they write, succeeded. The result was a scarcity of residency slots at medical schools—and the result of that was a shortage of doctors, especially primary care physicians. 

The Balanced Budget Act of 1997 also did not help, says Eric Wiser, MD, FAAFP, assistant dean of rural undergraduate medical education at OHSU. That law basically capped the number of residencies per institution to the number it was in 1997. And obviously, since population is far bigger now than it was 28 years ago, that number is inadequate virtually everywhere in the nation. So-called “capped naive” hospitals — those that didn’t have any residencies in 1997 — could create a residency program and then, in five years, it would be capped to however many residents it had. 

Residencies, which are mostly paid for by Medicare, are expensive for hospitals or Federally Qualified Health Centers to host. But also, for an institution to offer a residency, it must meet certain requirements: The facility has to perform a certain number of surgeries, births and so on. “Our rural sites don’t necessarily offer the volume that’s necessary,” says Robert Deuhmig, the director of the Oregon Office of Rural Health at OHSU. 

There used to be only five institutions in the state with primary care residencies — and now there are nine, says Betsy Boyd-Flynn, executive director at the Oregon Academy of Family Physicians (OAFP). At least two of those are in rural areas: Madras and Roseburg. Some of these are collaborations. For example, the site in Madras is a collaboration between OHSU and St. Charles Health System to offer three residency slots per year at St. Charles Madras, a critical access hospital. Residents here also do clinical experiences at a community health center that serves the Warm Springs Indian Reservation. Aviva Health partnered with Mercy Medical Center to develop the Roseburg Family Medicine Residency. Both of these residencies are partially supported by a Healthy Oregon Workforce Training Opportunity grant. HOWTO grants also support a residency in Newport and one in Cascade Locks, at Grain Integrative Health. 

Finally, insurance companies’ reimbursement rates for PCP visits and the preventive measures that PCPs take — including administering vaccines, ordering blood tests, talking about smoking cessation, etc.—are exceedingly low. And to make matters worse, they are less for those in a private family practice than for those who work for a big company like Cigna, Legacy or Providence, according to people I interviewed who have worked for family practices. PCPs who work for larger health care companies sometimes receive as much as double the reimbursement rates versus a physician who works at a private family practice, due to the negotiating power of a larger health care organization. 

“Primary care payment has not kept up with payments for procedures and some specialty care,” say Wiser at OHSU. “Most primary care doctors are employed by health care systems, and they invest in lines that pay the bills better. We are a fee-for-service model. We don’t make money to prevent things.” Yet, ironically, primary care is the only part of our health care system that has been proven to save money overall—and improve health, notes Boyd-Flynn. 

The doctor shortage in rural parts of the state is compounded by the fact that many of these regions lack affordable — or any — housing. Duehmig lives in Astoria and sees that problem close up. “It’s not as easy as being able to supply a house or buy a house, or even give a down payment for a house for somebody to move out, because there’s just limited supply in a lot of our areas. The reality is it’s more than just our doctors, nurse practitioners and physician assistants. Every level of health care worker at a hospital or clinic is struggling for decent housing in a lot of communities.” 

In its 2025 Health Care Workforce Needs Assessment, the Oregon Health Authority has suggested that increasing compensation for benefits like housing and child care could attract doctors to rural areas — but that only works if there’s housing to rent or buy and child care centers to subsidize. Lack of child care providers is a big problem in rural areas. Clatsop County, for example, is a child care desert. “So to say, ‘I’m going to provide you child care as a provider in the hospital’ is very complicated, because there is no child care in a lot of these communities—for anyone,” says Duehmig.

The Cure: Good Policy and Practical Incentives 

If you look closely at the OHA map, there’s one exception to the rural primary care doctor shortage: Wallowa County. This sprawling county in Eastern Oregon shows a rate of 34.6 PCPs per 10,000 patients. (The state average is 17 per 10,000 patients.) This is partially because the population of Wallowa County is so low, to be sure. Curious to see what Wallowa County was doing right, I asked Deuhmig at OHSU why he thought there were more PCPs here than in other counties relative to its population. He called out one Federally Qualified Health Center that’s done an impressive job of offering primary care residencies and retaining these residents: Winding Waters. 

Nic Powers, chief executive officer at Winding Waters, credits collaborations the clinic has with other institutions like OHSU, which sends all 12 of its primary care residents to do a rotation at Winding Waters. That rotation is part of the Cascades East Family Medicine Residency Program, which is a partnership between OHSU and Sky Lakes Medical Center in Klamath Falls. (The clinic also has a relationship with  Full Circle Health in Boise, Idaho.) Some of the residents fall in love with the beauty of the region but also with the broad scope of being a PCP in a rural area, where your job can include delivering babies, caring for someone in the ER and doing house calls — all in one week. 

Being an FQHC comes with enhanced funding — both in terms of reimbursements but also grants. And because Winding Waters is in a rural area, it can also offer loan repayments to those residents who want to stick on as physicians after their residencies end. 

In fact, Powers’ wife, Elizabeth, was a former OHSU resident 20 years ago, and she’s still a family physician at the clinic today. The couple, both of whom had grown up in rural areas — Nic in the backwoods of New Hampshire, Liz in Michigan’s Upper Peninsula — were drawn to the rugged beauty of Eastern Oregon. 

“It’s a three-legged stool,” says Powers about the clinic’s ability to seduce and retain top-notch talent. “We can do competitive wages and benefits, we have team-based care, and we’ve got loan repayment opportunity.” He also thinks that people’s stereotypes of rural America go out the window when they move to Wallowa County and see how artsy and interesting the region is — and also how welcoming the residents are. 

“If you live here, you’re either family, friends or neighbors,” Powers says. “We don’t agree about everything, but we are going to see each other at the grocery store or at the DMV or at the kids’ ballgames, and it’s really important that we take care of each other.” 

There are also some state legislative wins that should help alleviate the primary care doctor shortage in the state.   

One was Senate Bill 934, passed back in 2017 — which required every insurance company and Coordinated Care Organization in the state to allocate at least 12% of their total health care expenditures for primary care by 2023. The 2022 report shows that 12 are already achieving that goal: PacificSource CCO in Marion/Polk County (26.3%), Trillium Community Health Plan (24.2%) and PacificSource CCO Central Oregon (19.1%).

More recently Oregon Senate Bill 476 passed in the latest session and was signed by Gov. Kotek in July. SB476, whose chief sponsor was Kayse Jama (D-East Portland, Boring and Damascus), allows internationally educated and trained physicians to get a provisional license in Oregon and, after four years of full-time practice, a full license to practice medicine here. “The program is a win-win for our state,” said Jama in a press release. “It helps solve workforce gaps here and allows Oregon immigrants to continue in their chosen profession.” 

Finally, the Health Care Provider Incentive Program (passed by legislation in 2017) provides both loan forgiveness and loan repayment to med school graduates who commit to serving in rural or underserved communities for a number of years. From 2018 until June 2024, this program has already provided loan forgiveness to 72 primary care doctors who have served in rural parts of the state. The program has recruited an additional 335 doctors, behavioral health specialists and oral health providers (dentists, hygienists and dental assistants), who have had their loans repaid in exchange for serving in rural areas. This program has been funded to the tune of $26 million for the 2025-2027 biennium.

A decade ago, a group of doctors, policy directors and insurance provider directors formed the Primary Care Payment Reform Collaborative to come up with better ways to pay primary care doctors than the current “fee-for-service” model. One of the group’s ideas is “capitated payments,” which has also been put forth by the Centers for Medicare & Medicaid Services (CMS). Simply put, an insurance company would pay a clinic a set dollar amount for each of the patients it serves for a set time frame, such as once a month. 

“With fee-for-service, doctors need to increase the volume in order to meet their needs,” says Pierce-Wrobel. Capitated payments would give clinics a guaranteed monthly income and flexible funding to pay for additional staff whether they see a patient once or five times per month. It also reduces bookkeeping because there would be no need to bill for each individual service or test the doctor offers. The majority of Oregon’s Medicaid insurers already make capitation payments with some primary care providers.  

In its latest workforce needs assessment, the Oregon Health Authority published a long list of recommendations to help grow and diversify the state’s health care workforce. The list includes increasing compensation and other benefits (including offering stipends for housing, child care and transportation); reducing administrative burdens; increasing training opportunities and pre-college learning pathways for younger students — especially in rural areas; and continuing the Health Care Provider Incentive Program. 

In some good news from the federal government, the latest physician payment schedule for Medicare is increasing rates for primary care doctors in 2026. That’s important, says Pierce-Wrobel, because a lot of insurers base their own rates on Medicare’s fee schedule, which is publicly available. “This is something that you don’t see very often, and we’re interested in watching how that may slowly start to change in a direction that would move more investment into primary care,” Pierce-Wrobel says. 

At the end of the day, the primary care doctor shortage is going to take multi-pronged solutions: investment in residencies in rural parts of the state, perks (including housing, child care and other creative lures), and loan forgiveness and repayment programs.   

But some of the experts I interviewed said that the solutions need to start even further upstream.  

“I don’t care how many of these conversations or articles get published — or if you give me a billion dollars in my loan repayment and loan forgiveness programs,” says Deuhmig at OHSU. “We will never solve the problem of shortages of health care providers in rural areas unless we start educating rural kids in science and show them a pathway in which they can actually succeed,” says Duehmig. 

He points out that if you attend high school in Portland and then go to OHSU, you’re not likely to move to Baker City to practice medicine. “You might like it for a long weekend. You might go out and do some locums there,” he says, referring to the short stints doctors do to fill in for colleagues when they’re out sick or on vacation. “But you’re not going to move your family out.” But if you grew up in Baker City, you’re more likely to want to return because you have roots there.

These are hard problems, but they are solvable, says Boyd-Flynn at the Oregon Academy of Family Physicians. She points out that some of these issues — like lack of housing and day care, for instance—are community problems. “Communities need to get involved and push for change,” she says. “Employers should expect more emphasis on primary care in the health insurance they buy for their employees, and that might mean that health insurers have to pay more for that primary care,” she says. “Don’t settle for a new urgent care clinic when what people need is a primary care physician who can take care of them when things are not urgent.”   

***** 

Connie Cloyed eventually sold her house in Corbett, which she and her husband shared with their daughter, and moved to Netarts, 6.5 miles from Tillamook. She assumed correctly that she’d have a long wait to see a new PCP. In January she tried to make an appointment with a doctor of osteopathy at a Tillamook clinic. But even though the clinic’s website said she was accepting new patients, she wasn’t. (“That’s another thing. Nobody updates their websites!” Cloyed says, with exasperation.) But the receptionist recommended another M.D., and the first available appointment was at the beginning of September. 

“I was really excited! I said, ‘Whoa, honey! You should call this clinic right away. They have an M.D. who is accepting new patients!’”