I grew up in the small farming town of McFarland in California’s Central Valley, where John Steinbeck set his stories. My dad was a teacher and principal there for decades, and my mom counseled students at the same school. Together, they helped migrant farmworker children graduate high school and attend college, often the first in their families to do so.
I watched my parents for years before I understood what they were fighting against: the idea that where you are born determines how far you go.
Rural health care is losing that same fight right now, and for reasons most policy debates get wrong.
Rural Health Care Has a Talent Problem
Since 2005, 146 rural hospitals have closed. In 199 counties across the United States, there is not a single primary care provider. The policy response has focused on facilities, raising reimbursement rates and shoring up hospital operations.
I understand the impulse. I spent 20 years in health care, most of it in rural and underserved communities, running clinics, managing hospital operations and sitting in budget meetings where the central question was how to keep the doors open. The hardest problem I faced is the same one rural health leaders face today: nursing shortages.
Rural hospitals are not closing because of bad infrastructure. They are closing because the talent is out of reach.
The Bureau of Labor Statistics projects more than 190,000 nursing openings nationwide each year through 2032, and the shortage will not be evenly distributed. The Health Resources and Services Administration projects rural nursing shortages will exceed urban shortages by 2027. The problem is not a lack of people who want to become nurses. It is a lack of accessible, affordable education pathways for residents.
The Talent Is Already There
When I worked at Kaweah Health, we had four nursing programs within reach: two community colleges and two state universities. Because these schools received state funding, they could not give enrollment preference to local students. They admitted candidates from across the state, often students with enough economic mobility to apply everywhere and move wherever they got in.
Meanwhile, local students from farmworker families applied to the community college across the street year after year and got denied. Eventually, many gave up. They paid out of pocket to earn certificates as medical assistants or nursing assistants and spent their careers working at our clinic in lower-wage roles because the path to becoming a nurse remained out of reach. These were not people who lacked ability or drive. They lacked access.
The evidence is clear: training health care workers where they live is one of the most effective ways to keep them in rural communities.
The World Health Organization found rural-focused training programs have a 72.1% retention rate. The pattern holds across medical professions. According to the National Conference of State Legislatures, rural graduate medical education residencies have increased 51% over the past decade, and in 2023, 65% of physicians who completed rural residencies chose to practice in those communities. We know what works, but we are not building the pipeline that delivers it.
Train People Where They Live
At Kaweah, we built our own hospital-based nursing school to train local students for local positions. We gave enrollment preference to people already working in our system, individuals with deep community ties and every reason to stay. It was not a perfect solution, and it took years to build, but it worked. Locally trained nurses stayed. Most rural health systems lack the resources to build nursing schools from scratch, and they should not have to. The education system should be solving this.
Traditional nursing programs require proximity to campus, rigid schedules and resources to cover costs that frequently exceed federal loan limits.
What rural America needs from nursing education is the same thing it needed from my parents’ generation of teachers: to show up where people are, train the people already there and remove the financial barriers that base opportunity on income rather than ability.
Build Education Around Rural Learners
The tools exist, and they are not experimental. Online learning removes the geography barrier. Outcomes-based financing removes the credit barrier. Employer-funded repayment models remove the debt barrier, letting graduates start their careers focused on patients, not loan payments.
This model works. From 2021 through 2025, Western Governors University’s Leavitt School of Health produced 10,525 rural graduates across all 50 states, with more than 1,800 rural students graduating each year. An average of 97% stayed in their home communities one year after graduation. When graduates stay local, they fill critical gaps in the places that need them most.
Beyond digital instruction, several proven models bridge the gap for rural students. Hybrid programs combine remote coursework with hands-on skills labs scheduled locally on weekends or evenings. Earn-while-you-learn pathways let students work as certified nursing assistants while completing steps toward licensure. Regional satellite campuses and hospital-based partnerships put classrooms directly inside underserved communities and anchor talent locally.
Health system leaders in rural communities should ask every nursing school they work with one question: How many of your graduates are practicing in rural communities?
Stop investing in nursing education that exports talent. Start demanding education that keeps it.