Ed Friedmann, a physician assistant, says he takes great satisfaction in running his rural health clinic — Redfield Medical Clinic — the sole one of its kind in Redfield, Iowa. He has been seeing patients in the small town for about 40 years, tending to lacerations, colds, sore throats, and chronic illnesses such as diabetes. 

"I find it particularly satisfying because you're the only source of medical care in the area, so you're fulfilling a need that otherwise might not be filled," Friedmann told Medscape Medical News. "There's other small towns with no care available in their town."

And while he's managed to accomplish a lot in his career — like keeping his rural clinic afloat even when Medicare reimbursement rates for such clinic visits were much lower than they are today — he continues to face numerous challenges, such as physician assistants (PAs) generally not being authorized by Medicare to prescribe diabetic shoes when needed without a physician's involvement. 

While Friedmann is still healthy at age 79, he knows he won't be able to keep his medical practice — serving the town of approximately 810 people about 35 miles west of Des Moines — going forever. At some point, he will need to hand it off to someone new. But finding a health care provider who is willing to settle in a rural area and take over the job of running his federally certified rural clinic has proven a challenge. 

Doctors are unlikely to take over such a practice, he said, and PAs might be discouraged from doing so because they would need to pay a doctor to serve as a medical director as required by a federal regulation. This requirement is in place despite a 2023 Iowa law advocating that PAs generally do not need MD or DO supervision when starting in independent practice to increase access to healthcare in rural areas. 

Starting Out

Friedmann knows first-hand what it's like to live in a small town. He grew up in Luxemburg, Iowa, a small town near Dubuque. 

His mother was a nurse, and his father a dairy farmer. "That meant I got to milk cows," he said. 

After graduating from PA school, he landed a position in an Iowa Family Medicine physician residency training program in Mason City. Five years later, he became a PA program instructor and clinical coordinator at what was then the University of Osteopathic Medicine in Des Moines (now Des Moines University Medicine & Health Sciences or DMU). 

After Friedmann had worked there for 3 years, a physician directing a university-run health care clinic in Redfield had a heart attack and died, and the university asked Friedmann to run the clinic.

"… At the time they were saying: 'Well, let's see … how PAs do in these remote sites because they don't cost as much as what physicians do,'" he recalled.

After Friedmann worked at the clinic for about a year and a half, the university decided to close it, noting "the numbers aren't right."

It sent out notices to patients about closing the clinic, informing them they could come to Des Moines if they needed medical care. The news didn't sit well with Friedmann's patients, he said.

A 90-year-old patient called him that weekend saying: "'Going to Des Moines for me, it's like driving to the far side of the moon.'"

"So, I quickly scrambled and asked my wife if she would help me if I established a clinic," Friedmann said. His wife, Libby Coyte — also a PA who was working at a Federally Qualified Health Center in Des Moines at the time, in 1988 — agreed to help him. Friedmann then asked the university to allow him to take over the clinic. He proposed that way, they could still collect rent from him.

"And that seemed to persuade them," he said.

The patients stayed with Friedmann after he reopened as a federally certified rural health clinic serving a designated rural medical care shortage area. At that time, he recalls that PA services were generally not covered by Medicare in all settings, but working through a certified rural health clinic, he could receive Medicare coverage. By that point, the Rural Health Clinic Services Act of 1977 had gone into effect, which authorized Medicare coverage for PAs practicing in certified rural health clinics and significantly expanded PA autonomy. The law required such clinics to have a physician as a medical director. However, the level of physician oversight over PAs was left to the states to decide. 

This law — which addressed a shortage of healthcare professionals in rural areas — was important, Friedmann said, because it expanded insurance reimbursement for PA services in rural health clinics.

Over the years, the state requirements for a physician (MD or DO) to serve as medical director of a rural health care clinic evolved in Iowa. "They were kind of specific about it to start with. … A physician had to visit the clinic two half days a week, and then they went to one half day every 2 weeks. And finally, they said, ' … remote supervision is fine,'" Friedmann said. 

About 5 years ago, Friedmann and Coyte were able to purchase the clinic's building from the university. Friedmann's patients seem to be grateful for the clinic's continued existence. 

Last year, the clinic had 3500 patient visits, Friedmann said. About 50% of patients used Medicare, 25% used Medicaid, 20% were private pay, and 5% had no insurance. Patients come in with a variety of ailments, including acute injuries and respiratory illnesses. Some patients need pediatric or adult physicals. There is a sliding scale payment system.

'Makes a Difference'

Rural health clinics are vital, Friedmann said. 

They offer care to over 39 million Americans every year "and are the primary outpatient provider in rural, medically underserved parts of the country," Sarah Hohman, director of government affairs for the National Association of Rural Health Clinics, said in an email.

These rural clinics face the same challenges as primary care at large, but they are magnified, Bery Engebretsen, MD, said in an email. He has known Friedmann and Coyte for years, and Coyte worked with him at Primary Health Care Inc., a federally qualified health center in Des Moines, where he currently serves on the Board of Directors and was CEO in the past.

"The challenges include inadequate funding for primary care, accompanied by ever-increasing demands: workforce shortages in primary care (which is where the PA workforce becomes part of the solution); and difficulty accessing specialty care in rural areas, creating long travel times, and the critical need for emergency medical services, also often in short supply where most needed," Engebretsen wrote. 

"Prior to 2021, independent rural health clinics (those not owned by a hospital/ health system) were only eligible to receive reimbursement of up to $86 per Medicare encounter," Hohman said in an email. "This was resulting in significant closures of independent RHCs as this reimbursement was simply too low to survive on, in most cases."

Reimbursements have been incrementally going up every year, she said, and in 2026 reimbursement will have risen to $156 per encounter. "This is resulting in greater sustainability of independent RHCs," Hohman said. 

Local Care Prevents Disease, 'Builds Trust'

The thing about small-town clinics is "if you catch an infection while it's just bronchitis before it turns into pneumonia and requires hospitalization, the patient is happier. And so, it's good for the medical care system because … it provides more primary care," Friedmann said. 

Then there's the trust that local clinics can engender.

" … If you have local care, they're more likely to trust you and they're more likely to get their immunizations," Friedmann said of patients.

"It's uniquely satisfying to be the person that's providing the care where … otherwise they wouldn't have care," he said. "And it makes a difference."

There are other clinics at least 10 miles away from Redfield Medical Clinic, but they don't always have space for same-day visits, he said. The distance is a factor too. For example, many of Friedmann's patients are elderly — about half are age 65 or older — and some of them have restrictions on their driver's licenses in terms of how far they can drive. 

Other families have one car, and if somebody needs it to get to work while another family member is sick and needs care, that person must find their own transportation. That's where the ability to bike or walk to his in-town clinic can be helpful, Friedmann says. 

"Do you want a clinic that's a walking distance from you, or would you rather have one that's 10 miles away?" he said. 

But he's concerned about the clinic's future. At age 79, he acknowledges he can't work there forever. He needs to focus on finding someone to eventually take it over. 

" … Most physicians belong to the bigger groups. And these bigger groups are saying: 'Hey if the money isn't right, we're not staying,'" Friedmann said.

He recalls a similar refrain from local physicians before he took over the university-run clinic and turned it into the Redfield Medical Clinic in the late 1980s. He asked other doctors if they were interested. "No physician wanted to, no practice wanted to take the responsibility of paying the staff and seeing that the things are done the way they need to be done," he said.

Also, since wages are better in cities, recruiting staff can be challenging, too, he added. 

'Increasingly Reliant on Advanced Practice Providers'

Most of the rural health clinics in Iowa today are staffed at least partly by PAs or nurse practitioners, Friedmann said. But the requirement to pay for a medical director who is an MD or DO to oversee the clinic (up to $25,000 to $30,000 per year, he estimates) may be an impediment for certain PAs considering running one, he said. 

Iowa is considered a progressive state in terms of PA practice laws. In 2023, it generally allowed PAs with some experience to practice without a supervising physician. However, this rule doesn't apply to federally funded rural health clinics due to federal law, which Friedmann says is "outdated." Rural health advocates hope to change that federal requirement by making it consistent with the state law "to help keep care in our small towns," he said in an email.

Lack of health care in rural areas of Iowa is problematic, Friedmann said. 

"Rural America is increasingly reliant on advanced practice providers (encompassing both nurse practitioners and PAs) in that they provide the bulk of care in rural areas," Hohman said in an email. "However, varying scope of practice laws in each state can encourage PAs to practice in states where they can provide care to the top of their license, and not in others."

"Not utilizing our existing workforce to the level at which they were trained further exacerbates access to care challenges present across the country, and particularly in rural America," she wrote.

Bills have been introduced in Congress such as the Modernizing Rural Physician Assistant and Nurse Practitioner Utilization Act of 2025 which, if passed, would remove federal requirements for physician supervision that were more restrictive than the laws governing PAs and NPs at the state level. 

At present, 27 states have granted full practice authority for nurse practitioners and eight states for PAs, Hohman said in an email, " … yet NPs and PAs practicing in RHCs in those states must still have an MD or DO medical director, solely because they're practicing in an RHC. … This separate set of federal and state law that oftentimes conflict is only in place because the federal law hasn't been updated since 1977, despite scope of practice decisions now falling to the state level," she wrote.

Medscape reached out to the American Medical Association (AMA) to ask about their position on the Modernizing Rural Physician Assistant and Nurse Practitioner Utilization Act.

"The AMA's work on scope of practice is based on long-standing and extensive AMA policy and most often in direct response to legislative efforts that would dismantle physician-led care. Numerous studies show that patients have better outcomes when cared for by physician-led teams," an AMA spokesperson said in an email.

The AMA has opposed bills in the past that remove doctors' supervision of PAs. 

"Most PAs in rural areas are working where physicians don't practice, so it is puzzling why physicians would object," Engebretsen said in an email. 

"It's just like somebody with training wheels on your bike," Friedmann said. "Hey … when you're good enough to ride the bike without the training wheels, let them ride the bike without the training wheels. Don't insist they keep the training wheels on the bike."