Maintaining the healthcare workforce is fundamental to providing access to quality healthcare in rural areas.
Rural healthcare facilities must employ enough healthcare professionals to meet the needs of the community. They
should have adequate education and training, cultural competency skills, and hold appropriate licensure or
certification. When facilities promote coordination between health professionals and place them in roles where
their skills can be used to best advantage, patients will receive the best possible care.
Strategies for optimizing the use of health professionals in rural areas include:
Using interprofessional teams to provide coordinated and efficient care for patients and to extend the reach
of each provider.
Ensuring that all professionals are practicing to the full extent of their training and allowed scope of
Removing state and federal barriers to professional practice, where appropriate.
Changing policy to allow expansions to existing scopes of practice if evidence shows that the healthcare
workers can provide comparable or better care.
Removing barriers to the use of telehealth to provide access to remote healthcare providers.
As the United States struggles with healthcare provider shortages, an uneven distribution of workers means that
shortages are often more profound in rural areas. This maldistribution is a persistent problem affecting the
nation's healthcare system.
This guide examines policy, economics, planning challenges, and issues related to rural health workforce,
- Supply and demand
- Distribution of the workforce
- Characteristics of the rural healthcare workforce
- Licensure, certification, and scope of practice issues
- Programs and policies that can be used to improve the rural healthcare workforce
For additional information on rural healthcare workforce issues, see these RHIhub topic guides:
Frequently Asked Questions
Is there a healthcare workforce shortage in rural areas?
The National Rural Health Association (NRHA) policy brief Health
Care Workforce Distribution and Shortage Issues in Rural America, published in 2012, noted that
healthcare labor shortages were an ongoing problem, and offered the prediction that conditions were not expected
to improve significantly in the near future.
However, during the COVID-19 pandemic, the demand for healthcare has been unusual, with some facilities
experiencing decreased demand for routine and elective care while other facilities are experiencing
COVID-related surges, resulting in temporary alleviation or heightening of shortages of healthcare professionals
depending on local conditions.
Whether shortages exist in rural communities and how severe they are can be difficult to determine since
estimates of supply and demand for specific professions are not always available.
Maldistribution of healthcare professionals is also a problem affecting rural communities. The Association of
American Medical Colleges document The
Complexities of Physician Supply and Demand: Projections from 2017 to 2032 notes that as of 2017 an
additional 14,100 to 17,600 physicians were needed in nonmetropolitan areas in order to give underserved
populations the same access to care as populations facing fewer barriers. Areas with higher proportions of
low-income and minority residents, such as rural areas, tend to suffer most from lower supply of physicians and
other health professionals.
The following factors were identified in an interview with WWAMI
Rural Health Research Center researchers and in the NRHA policy
The current healthcare education system tends to be urban-centric.
Access to healthcare training and education programs may be limited in rural areas, particularly
beyond the community college level.
Providers trained in urban areas may not be prepared for the challenges of working in rural
communities or the kinds of health concerns rural patients may present.
Urban areas frequently draw potential healthcare professionals away from rural areas. Students in
rural communities may have to travel or relocate to an urban area for health professions coursework,
unless they can find degree programs offered online, or for clinical training. Some do not return to
rural communities after completion of their studies.
There are fewer clinician role models in rural communities.
Rural secondary school students may have fewer opportunities to receive the required math and
science courses needed to pursue health careers.
- Rural Demographics and Health Status
Rural populations usually have higher rates of chronic illness, which creates more demand.
Rural areas tend to have higher proportions of elderly residents, who typically require more care.
- Rural Practice Characteristics
The current healthcare system is designed around face-to-face contact. When rural communities lack
certain types of providers, particularly specialists, patients must travel longer distances or
Barriers such as reimbursement policies and lack of broadband availability have hindered
telehealth adoption in some rural areas. Many regulations related to telehealth have been relaxed or
temporarily suspended, as a result of the COVID-19 pandemic and the need for social distancing. It
remains to be seen whether these changes will remain in effect after the public health emergency
Rural communities may offer fewer opportunities for career advancement.
Understaffing causes increased workloads, longer shifts, and less flexibility in scheduling,
sometimes leading to burnout.
Urban facilities and practices may offer higher salaries, more benefits, and better working
Health professions that require longer and more expensive training can be less affordable for
Small, rural communities may offer fewer job opportunities for spouses, which can make recruiting
What is a Health Professional Shortage Area (HPSA)?
HPSA designations indicate shortages of healthcare professionals who provide primary care, dental, and mental
health services. HPSAs are designated by the U.S. Health Resources and Services Administration (HRSA). A
detailed description of HPSAs can be found at the HRSA Health Workforce's Types of Designations page.
HPSAs may be:
Geographic, based on the population of a defined geographic area
Population-specific, for a subset of the population in a defined geographic area, such as
those whose incomes are below 200% of the federal poverty level
Facility-based, such as public or nonprofit private clinics, state mental health hospitals,
and federal or state correctional facilities
In addition, there are safety net clinics that automatically receive shortage designation status. These include:
How are HPSA designations determined?
State Primary Care Offices are responsible for conducting needs assessments, to determine which areas within
their states should be considered shortage areas. They then submit applications to HRSA for review. For a fuller
explanation of the process, see the HRSA Health Workforce's Shortage
Designation Application and Review Process page. The primary factor used to determine whether a location
may be designated as a HPSA is the number of full-time equivalent healthcare professionals relative to the
population, with consideration given to high-need indicators such as a high percentage of the population living
at or below 100% of the federal poverty level.
Where are HPSAs located in rural areas?
The following maps show designated HPSAs for primary care, dental health, and mental health.
To search for HPSAs by state and county, see HRSA's HPSA Find tool. For statistics
on HPSAs, including national percentages of HPSAs located in rural and urban areas, see the data.HRSA.gov
What are Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs)?
Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) are federal shortage
designations that indicate a lack of primary care services for an area or a population. MUAs and MUPs are based
on four factors:
- Ratio of population to primary care providers
- Infant mortality rate
- Percentage of population below the federal poverty level
- Percentage of population over age 65
A list of MUAs and MUPs can be found at HRSA's Data Explorer. To
search for MUAs and MUPs by state and county, visit HRSA's website, MUA Find.
For further information on MUA/MUP designations, visit HRSA's website, Medically Underserved Areas
and Populations (MUA/Ps) or contact your state Primary
How do the distribution and characteristics of the healthcare workforce compare across rural and urban areas?
The following table shows ratios of health professionals per 10,000 population in rural areas as compared with
urban areas for select professions. With the exception of Licensed Practical Nurses/Licensed Vocational Nurses,
the supply of every type of health professional is lower in rural than urban areas:
Per Capita Rates of Health Professionals – Selected Occupations
||Health professionals per 10K, Rural
||Health professionals per 10K, Urban
|Licensed Practical Nurses/Licensed Vocational Nurses
|Primary Care Physicians
|Total Advanced Practice
|Source: HRSA Area Health Resources Files, 2017 and 2018.
Rural Primary Care Physicians
According to Figure 6 in the WWAMI Rural Health Research Center publication Supply
and Distribution of the Primary Care Workforce in Rural America: 2019, rural areas had more family
physicians per 100,000 population than metropolitan or micropolitan areas, but fewer pediatricians and internal
The WWAMI Rural Health Research Center's policy brief The
Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S. notes that rural areas
have seen a decrease in access to maternal care in recent years, due in large part to closure of obstetric units
and a shortage of healthcare professionals who deliver babies. There are significantly fewer obstetricians
serving non-metro counties, per 100K women of childbearing age, compared to
metropolitan counties. However, family physicians are more likely to deliver babies as the rurality of the
county in which they practice increases.
Rural Physician Assistants (PAs)
According to a June 2018 report
from the American Academy of PAs, as of 2017:
About 16% of all PAs in clinical practice were located in rural counties
39% of these rural PAs were practicing in primary care, compared with 21% of urban PAs
Family medicine was the primary specialty of 33% of rural PAs, in contrast to 14% of those in urban areas
11% of rural PAs and 9% of urban PAs practiced emergency medicine
Urgent care medicine was practiced by 9% of rural PAs and 6% of PAs in urban areas
19% of rural PAs were age 55 or older, as compared with 13% of urban PAs
Rural Nurse Practitioners (NPs)
According to Understanding Advanced
Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider
Identifier Data, as of 2012 there were 2.8 rural nurse practitioners (NPs) per 10,000 people, compared
with 3.6 in urban areas. Male NPs were more likely to practice in rural areas: 8.9% of rural NPs are men
compared with 6.8% in urban areas.
Rural Certified Registered Nurse Anesthetists (CRNAs)
According to Understanding Advanced
Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider
Identifier Data, as of 2010 there were 0.9 rural certified registered nurse anesthetists (CRNAs) per
10,000 people, compared with 1.2 in urban areas. Male CRNAs were more common in rural areas, with 60.9% of rural
CRNAs being male, compared with 38.5% of urban CRNAs. Among rural CRNAs, 66.8% practiced in large rural areas,
25.8% in small rural areas, and 7.3% in isolated small rural areas.
Rural Registered Nurses (RNs)
The Health Resources and Services Administration (HRSA) document The
U.S. Nursing Workforce: Trends in Supply and Education (2013) notes that rural RNs are:
About 16% of the RN workforce – From 2008 to 2010, there were 2.8 million RNs in the
workforce. Of that number, 445,000 live in rural areas.
Nearing retirement – Nearly one million RNs who are older than 50, about 1/3 of the
workforce, will reach retirement age in the next decade.
More likely to be White – 91.2% of RNs working in rural areas are White, compared
72.4% of RNs in urban areas.
Less likely to have a bachelor's degree – 51.6% of RNs working in rural areas have a
nursing diploma or an associate's degree as their highest level of education, compared with 35.3% of
their urban counterparts.
Less likely to work for a hospital – 59.4% of RNs working in rural areas are employed
hospitals compared with 63.9% of urban RNs.
The 2017 HRSA report Supply
and Demand Projections of the Nursing Workforce: 2014-2030 offers state-level projections for RNs and
LPNs for the year 2030.
Rural Licensed Practical Nurses (LPNs)
According to a report from HRSA, The
U.S. Nursing Workforce: Trends in Supply and Education (2013), rural LPNs are:
About 24% of the LPN workforce – From 2008 to 2010, there were 690,000 LPNs in the
nursing workforce. Of that number, 166,000 lived in rural areas. Thus, LPNs are disproportionately employed
in rural areas.
More likely to be White – 83.2% of rural LPNs are White, compared with 56.9% of LPNs
Less likely to work for a hospital – 28.8% of LPNs working in rural areas are
hospitals, compared with 29.5% of urban LPNs.
More likely to work in a nursing care facility – 33.5% of rural LPNs work in nursing
facilities, compared with 29.8% of urban LPNs.
Same age as urban LPNs – The average age of both rural LPNs and urban LPNs is 43.6.
Rural Behavioral Health Professionals
The WWAMI Rural Health Research Center's report Supply
and Distribution of the Behavioral Health Workforce in Rural America notes that although over 15 million
rural people currently have behavioral health issues, there are significantly fewer behavioral health providers
in rural areas than in metropolitan centers.
The following chart shows rates of providers in rural areas as compared with urban areas for selected behavioral
Per Capita Rates of Behavioral Health Professionals, 2013-2015
||Providers per 100K, Metropolitan
||Providers per 100K, Micropolitan
||Providers per 100K, Non-Core (Rural)
|Psychiatric Nurse Practitioners
and Distribution of the Behavioral Health Workforce in Rural America, WWAMI Rural Health
Research Center, 2016
What state-level policies and programs can help address the shortages in the rural healthcare workforce?
Funding options that states can use to address rural health workforce include:
Supporting healthcare education and recruitment to rural areas through grants, loans, fellowships,
loan repayment/forgiveness or scholarship programs, faculty loan repayment
programs, tax benefits, and other incentives
Increasing the number of healthcare graduates prepared for rural practice produced by state schools, by
supporting the development and growth of healthcare education programs with rurally oriented curricula
Supporting rural clinical training opportunities, including residency programs
Policy options that states can use to address rural health workforce shortages include:
Removing barriers to practice, such as allowing telehealth services to be provided across state lines
Allowing new or alternative provider types to practice in rural areas
Expanding existing scopes of practice
What can schools do to meet rural healthcare workforce needs?
Health professions schools can:
Use admissions criteria that are likely to produce providers interested in rural practice, such as
admitting more students from rural communities or who intend to practice in a rural community
Offer rural-centric curricula and training tracks
Develop distance education programs
See RHIhub’s Education and Training of the Rural Healthcare
Workforce for more information.
What strategies can rural healthcare facilities use to help meet their workforce needs?
Rural healthcare facilities can employ various strategies to ease healthcare workforce shortages and improve
care. For instance, they can use technology, such as telehealth, to fill gaps in care caused
by shortages. In addition, facilities can use interprofessional care teams to provide more
efficient and high-quality care.
Redesigning practice and processes to allow professionals to work at
the top of their license and skill set can also lessen the effects of shortages. Facilities can
provide workers with opportunities to learn new skills and encourage them to pursue career advancement through
apprenticeships and other educational opportunities.
Rural areas often experience difficulties related to recruitment and retention of primary care and other health
professionals. Thus, it is important to plan for future workforce needs. By anticipating
retirements and departures of staff, administrators can take steps to recruit replacements in a timely manner,
and avoid prolonged vacancies at their facilities. Increasing pay, benefits, flexibility, and opportunities for
career advancement can also improve chances for success with recruitment and retention.
For ideas on recruiting and retaining healthcare professionals, see RHIhub's Recruitment and Retention for Rural Health
How do foreign medical graduates help fill rural physician workforce gaps?
Many rural communities recruit foreign medical graduates with J-1 visa
waivers to fill physician vacancies. The Conrad State 30 Program allows each state's health department
to request J-1 Visa Waivers for up to 30 foreign physicians per year. The physicians must agree to work in a
federally designated Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA). Interested
parties should contact the Primary
Care Office in the state where they intend to work, for more information and exact requirements. See
RHIhub's Rural J-1 Visa Waiver topic guide for details.
In addition to the J-1 visa waiver, non-immigrant H-1B visas are sometimes used to fill employment gaps. These
are employer-sponsored visas for “specialty occupations,” including medical doctors and physical
therapists. H-1B visas are issued for three years and can be extended to six years. For more information, see
the U.S. Citizenship and Immigration pages on the H-1B
Program and H-1B
Where can I find statistics on healthcare workforce for my state, including data on employment, projected
growth, and key environmental factors?
HRSA's National Center for Health
Workforce Analysis provides in-depth data on supply, demand, distribution, education, and use of health
level profiles are available, which provide data for 35 types of health workers including physicians,
nurses, and dentists.
The National Forum of State Nursing Workforce Centers
provides a list of state nursing workforce center initiatives throughout the nation.
HRSA's Area Health Resources Files (AHRF)
provides demographic and training information on more than 50 healthcare professions.
The U.S. Department of Labor's Occupational Employment
Statistics: May 2021 State Occupational Employment and Wage Estimates provides state-level
information on occupational employment within “Healthcare Practitioners and Technical Occupations”
and “Healthcare Support Occupations.”
The Association of American Medical Colleges (AAMC)'s 2021 State Physician Workforce Data Report provides data on physician supply, medical school enrollment, and graduate medical education
throughout the United States. AAMC's Physician Specialty Data Report, published biennially, provides statistics on active physicians and
physicians in residency and fellowship programs for 46 specialty groups.
The Kaiser Family Foundation's State Health
Facts: Providers & Service Use Indicators provides data on physicians, RNs, PAs, NPs, dentists, and
The Robert Graham Center's
Workforce Projections provides primary care physician workforce projection reports for all states.
What are some federal policies and programs designed to improve the supply of rural health professionals?
Education Centers (AHEC) Program
AHECs promote interdisciplinary, community-based training initiatives intended to improve the diversity,
distribution, supply, and quality of healthcare personnel, particularly in primary care. The emphasis is on
delivery sites in rural and underserved areas. AHECs act as community liaisons with academic institutions and
assist in arranging training opportunities for health professions students, as well as K-12 students.
Health Careers Opportunity Program (HCOP)
HCOP works to increase the number of people from economically disadvantaged backgrounds who enter the health
professions field. HCOP programs provide student stipends and financial support to attend health professions
schools, training for disadvantaged students, and counseling and mentoring services to help students complete
their education and training. Students are exposed to community-based primary healthcare experiences.
National Health Service Corps (NHSC)
NHSC offers scholarships and loan repayment programs, which can enable students to complete health professions
training. Students must agree to complete a service commitment in a Health Professional Shortage Area. According
to the infographic Building
Healthier Communities, approximately 1 in 3 NHSC clinicians works in rural areas. This represents
more than 3,000 primary care clinicians, more than 3,400 clinicians working in the areas of mental and behavioral health,
and almost 700 dental clinicians.
Where can states get technical assistance for health workforce planning, including how to address rural needs?
The Health Workforce Technical Assistance Center (HWTAC) offers
technical assistance to states and organizations involved in health workforce planning. HWTAC activities can
- Direct technical assistance
- Educational webinars
- Facilitating access to health workforce data
HWTAC is a partnership of the Center for Health Workforce Studies (CHWS)
at the School of Public Health, University at Albany, State University of New York and the Cecil G. Sheps Center for Health Services Research at the
University of North Carolina. It is funded by HRSA's National Center for Health