Rural Healthcare Workforce
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 practice.
- 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, including:
- 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:
- Recruitment and Retention for Rural Health Facilities
- Education and Training of the Rural Healthcare Workforce
Frequently Asked Questions
- Is there a healthcare workforce shortage in rural areas?
- What is a Health Professional Shortage Area (HPSA)?
- How are HPSA designations determined?
- Where are HPSAs located in rural areas?
- What are Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs)?
- How do the distribution and characteristics of the healthcare workforce compare across rural and urban areas?
- What state-level policies and programs can help address the problem of shortages in the rural healthcare workforce?
- What can schools do to meet rural healthcare workforce needs?
- What strategies can rural healthcare facilities use to help meet their workforce needs?
- How do foreign medical graduates help fill rural physician workforce gaps?
- Where can I find statistics on healthcare workforce for my state including employment, projected growth, and key environmental factors?
- What are some federal policies and programs designed to improve the supply of rural health professionals?
- Where can states get technical assistance for health workforce planning, including how to consider rural needs?
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 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 forego care.
- 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 ends.
- 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 conditions.
- Health professions that require longer and more expensive training can be less affordable for rural students.
- Small, rural communities may offer fewer job opportunities for spouses, which can make recruiting providers difficult.
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:
- Federally Qualified Health Centers (FQHCs) and FQHC Look-Alikes
- Indian Health Service and tribal clinics
- Rural Health Clinics (RHCs) – must complete a Verification of Clinic Data, CMS Form-29 that certifies the RHC meets all NHSC site requirements.
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 Designated HPSA Statistics.
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
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:
|Occupation||Health professionals per 10K, Rural||Health professionals per 10K, Urban|
|Licensed Practical Nurses/Licensed Vocational Nurses||25.1||20.6|
|Primary Care Physicians||5.3||7.9|
|Total Advanced Practice Registered Nurses||6.5||8.1|
|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 medicine specialists.
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.
|Occupation||Providers per 100K women of childbearing age, Metropolitan||Providers per 100K women of childbearing age, Nonmetropolitan|
|Advanced Practice Midwives||11.3||8.7|
|Family Physicians Who Deliver Babies||9.8||34.4|
|Source: The Supply and Rural-Urban Distribution of the Obstetrical Care Workforce in the U.S|
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 current 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 with 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 in 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 in urban areas.
- Less likely to work for a hospital – 28.8% of LPNs working in rural areas are employed in 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 care 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 health professions:
|Occupation||Providers per 100K, Metropolitan||Providers per 100K, Micropolitan||Providers per 100K, Non-Core (Rural)|
|Psychiatric Nurse Practitioners||2.2||2.1||0.9|
|Source: Supply 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, scholarships, state 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 Facilities guide.
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 Specialty Occupations.
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 personnel. State 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 2019 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 2019 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 healthcare employment.
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 NHSC Builds Healthy Communities: 2020, approximately 1 in 3 NHSC clinicians works in rural areas. This represents 2,500 primary care clinicians, more than 2,500 clinicians working in the areas of mental and behavioral health, and about 600 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 include:
- 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 Workforce Analysis.
Last Reviewed: 11/9/2020