The Virginia State Capitol is not where most first-year medical students expect to spend a weekday. But earlier this year, a group of preclinical students made the trip to Richmond, advocating for bills like House Bill 663, a proposed Medical Education Loan-for-Service Program that would offer students up to $50,000 per year in exchange for practicing primary care in underserved communities. We were among them, motivated in part by genuine concern for rural health access and in part by a more personal anxiety. We are interested in primary care, but we are not yet sure the numbers make it possible.
Currently, what medicine needs does not align with what is financially rewarded. Rural communities are the first to pay the price for this misalignment. Rural healthcare gaps are often described as crises of hospitals, geography, insurance, or poverty. While that is true, at the center of many rural health challenges is a simpler problem: there are not enough primary care physicians. A recent Virginia-focused study found that only 56% of census tracts in the state had adequate access to primary care physicians, with rural communities having lower access than suburban areas. This reflects a broader national reality. One in five Americans lives in a rural area, and rural residents face persistent health disparities compared with people in urban communities, often resulting in poorer health outcomes. In 2022, the CDC found that rural counties had higher rates of potentially preventable early death from leading causes such as heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. Primary care cannot solve every rural health problem, but it is the part of the system most likely to keep patients healthy before they need emergency or specialty care. A national study published in JAMA Internal Medicine found that an increase of just 10 primary care physicians per 100,000 people was associated with a significant increase in life expectancy.
The physician pipeline, however, is moving in the wrong direction. Health Resources & Services Administration (HRSA) projects that nonmetro areas will experience an estimated primary care physician shortage of 39% by 2038, significantly worse than metro areas. These numbers should alarm state legislators. It takes more than a decade to educate and train a doctor. If states wait until shortages deepen, they will be trying to repair a pipeline that takes years to refill.
One reason the pipeline is so fragile is that primary care specialties are financially disincentivized. HRSA’s 2025 primary care workforce report identifies lower compensation relative to other specialties as a major barrier to recruitment. The same report lists average annual salaries for family medicine and pediatrics at around $281,000 and $265,000, compared with $564,000 and $544,000 for orthopaedics and plastic surgery. Simultaneously, AAMC reports that 71% of the medical school class of 2024 graduated with education debt, with a mean burden of $212,341 among those who borrowed, and 56% owing over $200,000. When a student is choosing between a lower-paying primary care career in a rural community and a higher-paying specialty in a metropolitan area, debt becomes a significant deciding factor.
We felt this acutely walking the halls of the General Assembly. Most of us were years away from residency, let alone independent practice, yet the financial arithmetic of our future careers was already shaping how we thought about what was possible. State-level loan forgiveness can change that calculation by opening up possibilities before financial pressure closes off certain paths.
Federal programs demonstrate that tying debt relief to service in shortage areas can bring clinicians to communities in need. The National Health Service Corps (NHSC) offers loan repayment to primary care clinicians who serve in Health Professional Shortage Areas. In fiscal year 2024, the National Health Service Corps Report to Congress reported that NHSC clinicians provided care to more than 18 million people, with 38.6% of placements at rural sites. But state governments understand their own shortage areas, medical schools, community health centers, and rural hospitals more intimately than Washington does. They can design incentives around their own workforce needs and align them with local training programs. Virginia already operates a State Loan Repayment Program for clinicians in shortage areas. HB663 would extend this logic upstream, intervening before financial pressure pushes trainees away from primary care.
The strongest version of such legislation should be targeted. It should prioritize primary care fields such as family medicine, general internal medicine, pediatrics, and obstetric care, where rural access is limited. It should require meaningful service in designated shortage areas, not vague promises to consider rural practice. It should be large enough to meaningfully offset debt burdens. It should also support retention by offering staged forgiveness over several years, with additional incentives for physicians who remain after the initial obligation. Studies of loan repayment suggest that such programs can influence not only whether clinicians choose rural practice, but also whether they stay. In one study of rural clinicians, loan repayment had an important influence on recruitment and retention. Rural communities need continuity, not a revolving door of short-term placements.
Critics may argue that loan forgiveness is expensive, but compared with what? The cost of untreated hypertension, avoidable hospitalizations, unmanaged diabetes, delayed cancer screening, and preventable emergency care is also expensive. So is the economic damage when rural hospitals struggle, clinics cannot recruit physicians, and patients must travel hours for care. A state loan-forgiveness program is not charity for doctors, but rather a public investment in the infrastructure of rural health.
If we want healthier rural communities, we must make primary care a viable choice for students and residents. We do not yet know where our careers will lead. But we know that in Richmond, we were advocating for something that would make it more financially realistic, for us and for students like us, to choose the kind of medicine that rural Virginians are already waiting for. Loan forgiveness tied to rural primary care service is not the whole solution, but it is one of the clearest places to start.
