Out of all 50 states, Iowa ranked 46th in 2016 for the total number of physicians active in patient care per 100,000 people, the Cedar Rapids Gazette reports. Recent reports by the Association of American Medical Colleges and the Robert Graham Center say Iowa would need a 5 percent increase in primary care physicians by 2030 just to maintain current care rates — not including the demand for medical specialists. Contributing to the shortage is the expected retirements of aging physicians and, surprisingly, the Balanced Budget Act of 1997 — which limited Medicare payments to teaching hospitals for residency and fellowship training for new doctors.