Every Health Care Occupation Is Scarcer in Rural America

Nonmetropolitan communities across the US have 44.4% fewer patient-facing health care workers per 10,000 residents than metropolitan areas. This gap widens sharply for the most highly trained clinical and behavioral health roles, according to a new cross-sectional analysis published in Annals of Internal Medicine.¹

The study used 2019-2023 American Community Survey (ACS) data to estimate workforce rates across 23 health care occupation groups by workplace urbanicity. They found that despite representing 13.8% of the US population, nonmetropolitan areas accounted for only 8.4% of the actively employed health care workforce. Strikingly, this disparity held true across every occupation examined.

Where the Gaps Are Greatest

The disparity was most pronounced among psychologists, who were nearly 74% less represented in nonmetropolitan areas compared with metropolitan areas (rate ratio [RR], 0.26; 95% CI, 0.23-0.30). Physicians followed closely, with nonmetropolitan areas having roughly one-third the physician rate of urban counterparts (RR, 0.31), and surgeons showed a similarly severe gap (RR, 0.35). Dentists, pharmacists, and physician assistants also fell well below proportional representation, with RRs ranging from 0.37 to 0.45.

As previously covered by The American Journal of Managed Care^® (AJMC^®), only 9% of US primary care physicians practice in rural areas, and 2022 data showed psychologist rates in rural settings (15.8 per 100,000 population) running at less than half the urban rate (39.5 per 100,000).² The new analysis adds important scope to that picture by quantifying disparities simultaneously across occupation categories using a single nationally representative data source.

The behavioral health picture is particularly concerning given the mortality burden already documented in rural communities. Nonmetropolitan areas have experienced rising excess deaths from chronic conditions, and the rural-urban mortality gap, roughly 6% in 1999, had grown to 18% by 2016.³ Workforce deficits in psychology, counseling, and social work compound that risk: the study found counselors and social workers in nonmetropolitan areas at roughly half the per-capita rate of their metropolitan counterparts (RR, 0.51).

A Pattern Tied to Training Level

The study identified a consistent structural pattern: Occupations requiring higher levels of formal training demonstrated greater metropolitan-nonmetropolitan disparities than related support roles. Physicians (RR, 0.31) were far more concentrated in urban areas than advanced practice nurses (RR, 0.57), and physical therapists (RR, 0.46) more so than physical therapist assistants and aides (RR, 0.79). Occupational therapists (RR, 0.50) showed a steeper gap than occupational therapy assistants and aides (RR, 0.75).

Nursing assistants (RR, 0.82) and physical therapist assistants and aides (RR, 0.79) were the most equitably distributed occupations, and in 2 sensitivity analyses, both showed significantly higher rates in nonmetropolitan areas, suggesting support roles may partially compensate for the absence of highly trained clinicians. Home health and personal care aides (RR, 0.61) also showed comparatively smaller gaps, pointing to a rural workforce that leans more heavily on these roles than its urban counterpart.

This compositional imbalance has direct implications for managed care organizations and health systems operating in rural markets. Workforce shortages in nonmetropolitan settings slow care redesign efforts, limit specialist coordination, and constrain the ability to implement population health strategies—challenges compounded by volatile patient attribution and a limited payer mix.⁴

Limitations and What Comes Next

The authors noted several important limitations. Because the ACS is a self-reported survey, practitioner specialties could not be assessed, and workplace urbanicity was assigned at the Public Use Microdata Area level, which is a geographic unit that cannot distinguish micropolitan areas from more deeply rural ones. The cross-sectional design captures workforce patterns from 2019 to 2023 and may not reflect more recent labor market shifts, including postpandemic telehealth expansion or the effects of new federal rural investment programs.

Notably, the study does not identify causes of the observed disparities or assess their direct impact on access, quality, or outcomes. As such, follow-up research to address these questions is needed. Still, the magnitude of the gaps, particularly for psychologists and physicians showing worker rates below half of urban levels in every analysis run, provides a quantitative baseline.

Federal efforts to address rural workforce gaps are ongoing. The Rural Health Transformation Program is slated to allocate $50 billion across states by 2030 for workforce development, chronic disease management, and delivery system reforms.⁵ Whether those investments will materially close the gaps documented here remains to be seen.

References

1. Burus T, Semprini J. A cross-sectional assessment of differences in the U.S. health care workforce by urbanicity, 2019 to 2023. Annals of Internal Medicine. 2026. doi:10.7326/ANNALS-26-00239
2. Shaw ML. 5 specialty care shortages in rural communities. AJMC. March 11, 2026. Accessed June 9, 2026. https://www.ajmc.com/view/5-specialty-care-shortages-in-rural-communities
3. Rosenberg J. Understanding the health challenges facing rural communities. AJMC. February 15, 2026. Accessed June 9, 2026. https://www.ajmc.com/view/understanding-the-health-challenges-facing-rural-communities
4. McDermott M, Chouinard S, Fadahunsi O, et al. Contributor: accountable care and rural access—why new transformation grants should enable payment reform. AJMC. June 2, 2026. Accessed June 9, 2026. https://www.ajmc.com/view/contributor-accountable-care-and-rural-access-why-new-transformation-grants-should-enable-payment-reform
5. McCormick B. Clinician shortages, access gaps challenge rural primary care. AJMC. November 17, 2025. Accessed June 9, 2026. https://www.ajmc.com/view/clinician-shortages-access-gaps-challenge-rural-primary-care