The State of Rural Primary Care in the United States

Introduction

Primary care is facing existential challenges — from lower relative investment compared to specialty care to clinician burnout — which are particularly acute in rural communities.¹ For the more than 60 million people, or one in five Americans, who live in rural areas, strengthening primary care requires rural-specific solutions.²

Rural clinician shortages, limited broadband internet, and a lack of public transportation in rural areas make it difficult for patients to get health care, either in person or virtually.³ These access challenges are associated with poor health outcomes, low uptake of preventive services, and overreliance on costly emergency department visits for nonurgent health needs.⁴

Nearly half of rural residents are uninsured or insured by public payers.⁵ This limited payer mix, coupled with relatively low reimbursement rates and high provision of uncompensated care compared to nonrural areas, poses challenges to the financial stability of rural primary care.⁶

Despite these challenges, rural communities have developed innovative, place-based solutions to their health care access problems, such as mobile health units, Rural Health Clinics, and other community-directed health programs that help meet local needs.

State and congressional policymakers are also investing in rural health. For example, H.R. 1, the recently passed tax and spending law, includes the Rural Health Transformation Program, which allocates $50 billion for states over the next five years to strengthen care delivery.⁷ National and local strategies to improve primary care access and quality will be key to ensuring better health outcomes for rural residents.

Drawing from the Commonwealth Fund 2023 International Health Policy Survey and federal health workforce data, we describe the current state of U.S. primary care across rural America, focusing on the workforce, access to care, and care delivery. We also highlight innovative rural primary care delivery models and regional differences where data are available (see “How We Conducted This Study” for more detail).

Study Findings

The Rural Primary Care Workforce

The Health Resources and Services Administration (HRSA) projects that by 2037, only 68 percent of demand for rural primary care physicians will be met, compared to 73 percent nationally (data not shown).

To help fill physician shortages, practices may engage advanced care practitioners such as nurse practitioners and physician assistants. While these clinicians cannot fully replace the role of physicians in primary care delivery, they can expand the capacity of primary care practices and mitigate the impacts of shortages. HRSA projects that the supply of nurse practitioners in rural areas will continue to exceed demand over time, partly because nurse practitioners are the fastest-growing type of clinician in our health system, regardless of geography.⁸ Additionally, while the supply of physician assistants relative to demand will likely decrease, it will do so more slowly than for physicians. While not included in this map, community health workers could also fill gaps in rural communities (see “Kentucky Homeplace: Augmenting the Workforce with Community Health Workers” to learn more).

While advanced care practitioners play a growing role in primary care, concerns about workforce availability remain. Across the health system, fewer trainees are opting to practice primary care, and even fewer are choosing to work in rural areas.⁹ It’s possible these trends may not play out as projected.

In 2023, 92 percent of rural counties were designated primary care health professional shortage areas (HPSAs), compared to 83 percent of nonrural counties (data not shown). HPSAs are geographic areas that the federal government determines have inadequate health care resources relative to community needs. We estimate that 42.6 million people lived in a rural primary care HPSA in 2023, compared to 260 million people in nonrural primary care HPSAs (data not shown in map).

There is substantial regional variation in health professional availability. Ninety-seven percent of rural counties in the South and West are either partially or wholly designated as primary care HPSAs, compared to 84 percent in the Midwest.

Additionally, 45 percent of rural counties had five or fewer primary care physicians, including 199 rural counties without any. On average, there was one rural physician per 2,881 residents. This ratio similarly varied by region, with a higher average proportion of patients to physicians in the South (3,411:1) than the Northeast (1,979:1) (data not shown).

Clinicians who work in rural areas often remain in those places, making place-based training or incentive programs an effective way to address shortages.¹⁴ The National Health Service Corp (NHSC) is one such program. This federal initiative provides loan repayment and scholarships to clinicians working in HPSAs.

Forty percent of rural counties had at least one NHSC primary care clinician in 2023, compared to 60 percent of nonrural counties (data not shown), an indication the program could be expanded further in rural communities.

The NHSC program has been effective at retaining clinicians in underserved areas, including rural communities, with 84 percent of participants staying in an underserved area for at least one year after their service year ended.¹⁵

Rural residents are accessing primary care through clinics designed for their communities, such as a Rural Health Clinic (RHC) or a Federally Qualified Health Center (FQHC). In 2021, 90 percent of rural counties, with a total population of 42 million people, had one or the other providing primary care services (data not shown).

RHCs, located in rural areas with health professional shortages, are eligible for enhanced reimbursement rates from CMS. FQHCs, overseen by HRSA, are community-based outpatient clinics funded through federal grants and reimbursements that provide services to patients regardless of their ability to pay.

The Rural Patient Experience

Having a usual place to get primary care makes it easier for people to receive preventive care, detect diseases and receive treatment in a timely manner, and manage chronic conditions. Patients with a usual place of care are also more likely to receive recommended immunizations and health screenings.¹⁹

Despite most adults reporting they have a usual place of care, access issues remain. About one in four adults in rural areas reported going to the emergency room in the past two years for something that could have been handled by their usual doctor if they had been available. A similar share of rural adults reported not going to the doctor when needed because of the cost, which can contribute to higher rates of chronic disease, suicide, and poor maternal health in rural areas.²⁰

Even if people know where to get primary care, it must be easily accessible and affordable to be effective. We’ve found that in rural communities, clinician and appointment availability, as well as costs of care, are a challenge.

Only four in 10 working-age rural adults can get same-day or next-day primary care appointments, and about one in three said they could easily get after-hours care — both of which are necessary for minimizing unnecessary emergency room utilization. Timely access is compromised when there are fewer clinicians available per patient.

While use of telehealth for primary care services has decreased since peaking during the COVID-19 pandemic, technology still offers a solution to some traditional access problems, particularly in rural areas where people often have to travel longer distances to see their doctor.²¹ However, only two in 10 working-age rural adults reported receiving primary care via telehealth in the past 12 months, compared to three in 10 nonrural residents (a statistically significant difference).

Obstacles to widespread use of telehealth services in rural areas include limited access to high-speed internet and inadequate reimbursement for such services.²² Clinician have also raised that telehealth licensing can be burdensome and time-prohibitive.²³ Without addressing these challenges, it will be difficult for rural clinicians to sustain telehealth delivery.

Discussion

Rural Americans face significant barriers to accessing adequate primary care services, from workforce shortages to the expenses of care. However, we found that federal and state programs tailored to rural America — such as Rural Health Clinics, the Rural Health Transformation Program, and clinician training and loan payment programs — can help address some of these challenges. In addition to programs already underway, policymakers and delivery system leaders can take additional steps to strengthen rural primary care.

Design rural-specific financing options. Our health care payment models are designed for higher-volume service areas and don’t account for the realities of rural care delivery, including lower case volume, lack of specialists, and greater operating costs.²⁴ Clinicians have also noted that lack of telehealth payment parity is a challenge, regardless of geography, and implementation costs can be high in rural areas.²⁵

Payment reform such as enhanced reimbursements, bonus payments, upfront infrastructure investments, and payments tied to operational costs could play a role in mitigating the lack of funding in rural care delivery. Evidence shows that rural-specific payment models, like the Pennsylvania Rural Health Model, which provides consistent payments untied to patient volume, has the potential to provide greater financial stability and better patient outcomes.²⁶

Grow the pipeline of health care clinicians. Living or training in a rural area make it more likely that clinicians will practice in a rural area.²⁷ Delivery system and policy leaders can grow the rural workforce pipeline by targeting local recruitment of health care workers, incorporating rural rotations into medical school training, increasing opportunities for rural residencies and experiential learning, and incentivizing practicing in rural areas through loan repayment programs.

Strengthen rural technology infrastructure. Technology can play a major role in increasing access to health care for rural residents, but as our survey data show, telehealth is not widely used, likely owing to limited internet access via broadband or satellite. Policymakers can invest in broadband infrastructure. They also can promote payment parity and training for telehealth and other digital innovations, such as through regional resource centers, to ensure clinicians have the capacity and financial means to deliver telehealth care.²⁸