BOISE, Idaho — You’ve seen the headlines before: Idaho has a shortage of physicians. But just how short are we?

Idaho ranks at the bottom of all 50 states for its supply of doctors per capita. Even in areas of the state with high population density, such as the Boise area, patients often face months-long wait times to see primary care physicians, even though most providers are already concentrated in the those places.

And a slew of factors threatens to make matters worse.

Saltzer Health, a medical group with 11 clinics in the Treasure Valley, announced mid-January that it would close completely by the end of March absent a last-minute sale, prompting new worries that access to health care in the fast-growing region is deteriorating. Saltzer sees about 100,000 patients a year, including over 35,000 primary-care patients, Dr. Erik Richardson, associate medical director of family medicine at Saltzer, told the Statesman.

In late February, a new report revealed that dozens of Idaho’s obstetricians have stopped practicing in the state since Idaho’s abortion law took effect in August 2022.

Policy decisions, like Idaho’s strict abortion ban, have had a “chilling effect” on recruitment and retention of the state’s already slim body of physicians, the impacts of which are felt beyond the health care industry, says Dr. Edward McEachern, a general internist, pathologist and health services researcher. McEachern retired in January, and now works at Boise State University as a distinguished scholar in residence.

Brian Whitlock, president of the Idaho Hospital Association, told the Statesman he recently spoke with a hospital CEO who explained how a physician the hospital was recruiting for its emergency room “declined the offer, saying he was not willing to come to a state that criminalizes physicians.”

“And that is starting to become a pretty common response from people who say, ‘No, I’m not coming to Idaho to practice medicine,’” Whitlock said by phone.

Abortion law threatens criminal charges

Idaho’s abortion ban, one of the most restrictive in the country, has been the catalyst for an exodus of reproductive health providers from the state.

The ban took effect shortly after the U.S. Supreme Court overturned Roe v. Wade in June 2022, eliminating the long-established constitutional right to abortion and leaving the divisive issue up to individual states to legislate.

Now, doctors in Idaho who provide often necessary medical care for pregnant patients face being charged with a felony punishable by up to two to five years in prison, and having their medical license suspended for a minimum of sixth months for a first offense and permanently revoked upon a subsequent offense. The only exceptions the law provides are for rape, incest and to “prevent the death of the pregnant woman.” There are no exceptions for the health of the pregnant patient.

The exceptions for rape and incest are only allowed in the first trimester of pregnancy and require victims to report the incidents to the police and provide a copy of the report to the physician that would perform the abortion.

The Legislature passed an exception to the abortion ban last year that clarified the prohibition does not apply to ectopic or molar pregnancies, the Statesman reported. But lawmakers blocked an effort to include exceptions for when a pregnant patient’s health is at risk.

Doctors also worry they could be prosecuted for referring patients to states where abortion is legal, like in Oregon and Washington.

The Idaho Academy of Family Physicians, a trade organization with over 650 members across the state, joined two Idaho physicians and four women in suing the state of Idaho over the ban. The lawsuit, filed in September, seeks to clarify what circumstances qualify for emergency exceptions. The four women named in the lawsuit had to travel out of state for procedures after experiencing dangerous pregnancy complications.

The physicians group said in the lawsuit that many members are “afraid to have open and frank conversations” with patients about the options available to them, including when a complication arises.

Dr. Julie Lyons, a plaintiff in the lawsuit, noted that abortion is often the medically necessary option for many pregnancy complications, not just an elective procedure. Lyons said it now takes longer to get patients a diagnosis, and routine procedures like ultrasounds are delayed.

Obstetricians flee Idaho

The Idaho Physician Well-Being Action Collaborative, which McEachern co-chairs, released a report in February that said 22% of Idaho obstetricians have stopped practicing in the state in the first 15 months since Idaho’s abortion ban took effect.

Given the threat of criminal charges under the ban, he said, “it’s really not a mystery” why so many obstetricians have chosen to retire, quit or leave the state altogether.

“There is a sacred relationship that most physicians go into medicine for, which is the relationship between a patient and a doctor. It is very personal, very private and very sacred,” McEachern told the Idaho Statesman. “If you back up and think about what the state legislature is doing … it signals that there are people willing to step in there and begin to tell a physician how they should practice. That has a very chilling effect. It signals that the patient-provider relationship is no longer sacrosanct.”

“And by the way, there’s not a single physician in the state legislature,” he added.

The report notes that Idaho had 268 obstetricians in August 2022, and by November 2023, was down to 210 obstetricians, a loss of dozens of obstetricians during a period where only two obstetricians moved into the state to practice. There is now one obstetrician per 8,510 Idahoans.

Researchers estimate the number of full-time obstetricians is even less, since the study accounts for both full-time and part-time workers.

The vast majority, about 85%, of obstetricians and gynecologists in Idaho practice in the seven most populous counties. And only 22 of 44 counties have access to any practicing obstetricians, the report said.

Obstetrics is the branch of medicine concerned with the care of women during pregnancy and childbirth.

“It’s not just a pregnant person issue — obstetricians are specialists in women’s health,” McEachern said by phone. “We have family medicine residencies here in Idaho, but we don’t have any obstetrical residencies. So every obstetrician who is here wanted to be here. And they often teach the family medicine doctors, nurse practitioners and nurse midwives how to practice obstetrics.”

Maternal-fetal medicine doctors, that is, obstetricians who undergo three additional years of training to manage the most complicated and high-risk pregnancies, are also leaving. The report said that 55% of these specialists have stopped practicing in Idaho in the last 15 months.

Of the nine maternal-fetal medicine specialists who practiced in Idaho before the state’s abortion ban took effect, only four are left.

“Those doctors are superheroes,” he said. “They take care of the sickest babies and the sickest moms.”

In July 2023, Idaho legislators disbanded the state’s Maternal Mortality Review Committee, a volunteer cohort of medical and public health experts that investigated the root causes of deaths during and shortly after pregnancy, making it the only state in the nation with no such maternal mortality review.

Dr. David Pate, a retired physician and the former CEO of St. Luke’s Health System, told the Statesman said some of those specialists have left “because of actions the Legislature has taken.”

“If you’re in a high-risk pregnancy, you’re thanking your lucky stars every single day that we have them,” Pate said by phone.

A survey of physicians by the Idaho Coalition for Safe Reproductive Health Care in 2023 found that over half of obstetricians and gynecologists surveyed were considering leaving Idaho. Of those, 96% said they would reconsider or very likely stay if a health exception was added to the state’s abortion law.

‘You’re going to scare doctors away’

Since the ban was enacted, three rural hospitals have closed or announced closure of their labor-and-delivery centers, and medical leaders say they’re struggling to recruit new staff. Bonner General Health, a critical access hospital in Sandpoint, Idaho, said in March 2023 that it would soon shutter its labor and delivery unit, citing the state’s legal and political climate as one of the reasons.

“Highly respected, talented physicians are leaving,” the hospital said in a news release. “Recruiting replacements will be extraordinarily difficult. In addition, the Idaho Legislature continues to introduce and pass bills that criminalize physicians for medical care nationally recognized as the standard of care.”

Since then, two other Idaho hospitals have followed suit. Valor Health, the only hospital in Emmett, halted its labor-and-delivery services to the city of nearly 8,000 people in June, citing financial challenges and an ongoing staffing crisis. West Valley Medical Center in Caldwell plans to close its labor and delivery and neonatal intensive care units by April 1 for similar reasons.

But obstetricians and maternal-fetal medicine specialists aren’t the only doctors who don’t want to practice in Idaho, under the threat of prison time and professional ruin. Other specialties are struggling to recruit new physicians, too.

And a rising tally of health care workers “feel a complete lack of respect from the state’s governmental leadership,” Steven Reames, executive director of the Ada County Medical Society, told the Statesman.

Pate agreed and said that doctors, especially those with children, may be hesitant to move to a state often criticized for the way it funds public education.

A statewide survey commissioned by the Statesman in 2022, conducted by independent research company SurveyUSA, found that a majority of residents believe the state spends too little on education.

“Doctors are highly educated,” Pate said. “They value education. So when they see that there’s all these attacks on schools and talk about vouchers and that kind of stuff — you’re going to scare doctors away. You’re going to scare the highly educated away. And that’s a shame, because these folks are huge taxpayers.”

Months-long wait times

Should Saltzer close, Richardson, the associate medical director of family medicine at Saltzer, said it could take up to several months for its physicians to find new employment or establish their own practices. And transitioning the medical group’s patients to other providers in the short timeframe before it’s poised to shutter presents another significant hurdle.

Reames said he’s heard from more than one source that over a quarter of Saltzer’s physicians are considering opening their own independent practices, and some are already working on ironing out those plans. He mentioned two events he’d attended recently where Saltzer doctors met with others who shared resources on how to do just that.

“They’re just going to bite the bullet and do it,” Reames said by phone. “Which, to do that in a less than three-month period … one physician who emailed me said, ‘I’m terrified.’ You’ve got to be in a position to unload that much capital, you’ve got to rent a building, you’ve got to hire staff, you’ve got to buy an electronic health records system, all these things.”

As for the rest of Saltzer’s doctors, he “suspect(s) very few of them will leave the community or the state,” instead joining other medical groups or health systems.

Dr. Jesse Chlebeck, an orthopedic surgeon and the associate medical director of orthopedics are Saltzer, told the Statesman he’s hard at work on his own plans for a private practice. He said he wants to get it up and running as fast as possible, so he can keep caring for his current patients.

“It’s a huge undertaking,” Chlebeck said by phone.

Another Saltzer leader, Dr. Mark Rasmus, is also hoping to open his own private practice. Rasmus is a sleep medicine specialist and board member at Saltzer. He’s worked at the medical group for over 15 years.

He told the Statesman he cares for a number of chronically ill patients, including people with narcolepsy, and wants to continue treating them regardless of what happens to Saltzer. He said he’s been losing sleep over what will happen to those patients.

“Most medical practices throughout the Valley are busting at the seams,” he said by phone. “When you try to get an appointment, either with a primary care doctor or a specialist like myself, people wait upwards of five months to get an appointment. Where will they go to get their medications refilled, or their oxygen prescriptions refilled? There’s just not the capacity in the community to absorb that.”

At St. Luke’s, spokesperson Christine Myron told the Statesman in late January that the soonest available appointment with a family-medicine physician across its Valley clinics was in May. Pediatric care appointments are easier to snap up, at about a month-long wait. But wait times can change quickly, Myron said.

She added that the health system is committed to helping fill any gaps in access to care that Saltzer’s potential closure may create, and that its physicians are welcome to apply for open positions at St. Luke’s.

As Saltzer teeters on the brink of collapse, another chain of urgent care clinics is expanding. Sterling Urgent Care, an employee-owned multipractice physician group with clinics in Idaho, Utah and Wyoming, opened four Treasure Valley locations in late January, with a fifth slated for later this spring. The clinics are Sterling’s first in the Boise area. The four clinics are located in Boise, Garden City, Meridian and Nampa.

Riverside Primary Care, an independently owned primary care group formed in May, opened its first clinic in January in downtown Boise. It’s led by two nurse practitioners.

Primary Health Medical Group, the largest independent medical group in the state, has 23 clinics in the Boise area.

How short is Idaho on doctors?

In 2022, the latest year for which data is available, there were an estimated 3,723 physicians practicing in Idaho, according to the Association of American Medical Colleges.

Of those physicians, 27.7% were female, and 19.3% were age 65 or older.

Among states, Idaho had the lowest number of active physicians at 192 per 100,000 people, down from 196.1 in 2020; and the lowest number of direct patient-care physicians, at 178 per 100,000 people. Massachusetts had the highest number, with 480 and 369, respectively. Nationally, there were 297 active physicians and 252 direct patient-care physicians per 100,000 people.

Idaho was also ranked among five states including Utah, Nevada, Texas and Oklahoma that had the lowest number of direct patient care general surgeons at five per 100,000 people. The national average was 7.6. It also had the lowest percentage of active physicians who were international medical school graduates.

The state is projected to be short 1,743 doctors by 2030, per a study published in Human Resources for Health that forecast nationwide physician shortages.

St. Luke’s, the largest health care system in Idaho, says it employs 333 primary-care physicians in Boise, Meridian, Eagle and Nampa, along with 328 physician assistants and nurse practitioners. Those numbers don’t include providers who exclusively perform urgent-care services.

Physician assistants, or PAs, and nurse practitioners, or NPs, are mid-level medical professionals who undergo less schooling and training than physicians.

Rural counties bear the brunt

Federal data shows that nearly every county in Idaho does not have enough primary care physicians.

The U.S. Department of Health and Human Services has designated 43 of Idaho’s 44 counties as primary care “health professional shortage areas,” known as HPSAs. The government list was created to help funnel physicians to areas where they’re needed most.

Ada County is the only Idaho county without a primary care geographic or population shortage area designation.

There are other types of health professional shortage areas, like for facilities.

Facilities with the designation include nonprofit and for-profit medical clinics, state and county mental hospitals, correctional institutions, federally qualified health centers and certified rural health clinics that serve a population or geographic area with a shortage of providers. Among the rural health clinics with the designation are St. Luke’s family medicine clinic in Jerome and Saint Alphonsus Health System’s family medicine clinic in Fruitland.

“You have people having to travel very long distances to get health care,” said Pate, who noted the broadest array of Idaho’s specialists are located in the state’s metropolitan hubs.

The state’s only pediatrics hospital, St. Luke’s Children’s Hospital, is located in downtown Boise. Saint Alphonsus’ flagship hospital in Boise had the only trauma-center certified by the industry’s national accrediting organization, the American College of Surgeons, though it lost that distinction late last year and is actively working to get it back.

“We have the breadth of specialties and sub-specialties here in the Treasure Valley,” Pate said. “But also, there is so much pent up demand. The state is getting all this growth, and most of it is in the Treasure Valley.”

Even though the Valley has increased its number of doctors and specialties over the years, it’s not enough to keep up with the area’s rapidly growing population, he said.

Idaho is slated to surpass 2 million residents within the next two years, the Idaho Department of Labor predicts. The state grew by nearly 26,000 people between July 2022 and July 2023, and much of that growth was in the Boise metropolitan statistical area, which includes Ada, Canyon, Owyhee, Boise and Gem counties.

Idaho’s limited medical-education options

Part of struggle to retain and recruit new physicians in the state stems from its limited access to medical education.

Idaho is among just five states that do not have a doctor of medicine-granting school, though the state has an agreement with the University of Washington School of Medicine in Seattle that reserves a limited number of undergraduate medical education slots for University of Idaho students.

Idaho subsidizes part of the cost of tuition and fees for each student admitted to the program, known as the Washington, Wyoming, Alaska, Montana and Idaho Regional Medical Education program, or WWAMI.

The state has just one doctor of osteopathic medicine-granting school, the Idaho College of Osteopathic Medicine in Meridian, which is a private medical school affiliated with Idaho State University.

Could telemedicine help fill the gap?

Myron, the spokesperson for St. Luke’s, noted that an option available to patients today is St. Luke’s On-Demand Virtual Care service, established in 2021. She said any patient who has a concern or experiences a gap in care can utilize the service.

The technology could help with a shortage of psychiatrists in Idaho. Pate said child psychiatry, in particular, is an area where more specialists are needed.

“We certainly recruited some child psychiatrists at St. Luke’s, and we tried to hang onto them for dear life,” Pate said of his time overseeing the health system. “We lost one that, as far as I can remember, was the only child psychiatrist in the Magic Valley. And for children with these issues, it can be really, really tough not to have access to that expertise.”

But there are some voids telemedicine just can fill.

“It might work for psych, but it really doesn’t work for obstetrics,” McEachern said. “There’s many things where you’re going to need a doctor right there, right now.”

He said the obstetricians he’s spoken with were hoping for something to come out of this spring’s legislative session that would make it “at least tolerable” for them to continue practicing in the state. If nothing does, it’s likely more will leave, he said.

He cited Boise State’s latest public policy survey, published in January, that found most Idaho residents favor making the state’s strict anti-abortion laws less severe.

McEachern also said Idahoans have a “Git-R-Done” attitude. The state is small enough, and practical enough, he said, that if the political will is there, Idaho could drive legislative policy that attracts doctors, instead of scaring them away.

“Maybe I’m Pollyanna,” he said. “But I would really like to figure out a way to do that.”