Clinician Shortages, Access Gaps Challenge Rural Primary Care

Rural primary care is under significant strain due to clinician shortages and limited access, according to a report published today by The Commonwealth Fund, underscoring the need for reforms to strengthen care delivery and improve patient outcomes.1

Targeted financing, clinician recruitment, and telehealth expansion are needed to improve rural primary care. | Image credit: BJP7images - stock.adobe.com

Identifying Key Challenges Impacting Rural Primary Care

The researchers explained that primary care is facing “existential challenges” nationwide, particularly for the more than 60 million people living in rural communities. Clinician shortages, limited broadband internet, and inadequate public transportation make it difficult for patients in rural areas to receive health care in person or virtually. They noted that these barriers contribute to poor health outcomes, low uptake of preventive services, and an overreliance on costly emergency department visits for nonurgent care.

Additionally, nearly half of patients in rural areas are uninsured or rely on public insurance. The researchers highlighted that this limited payer mix, combined with relatively low reimbursement rates and higher levels of uncompensated care than in nonrural areas, threatens the financial stability of rural primary care practices.

To better understand these challenges, they analyzed data from the Commonwealth Fund 2023 International Health Policy Survey, supplemented with Health Resources and Services Administration (HRSA) data. They used this information to describe the current state of rural primary care, focusing on the workforce, care access, and care delivery.

Rural Primary Care Workforce and Access Challenges

HRSA projects that only 68% of the demand for primary care physicians in rural areas will be met by 2037 compared with 73% nationally. To help fill gaps, practices increasingly rely on advanced care practitioners such as nurse practitioners and physician assistants. Although these clinicians cannot fully replace physicians, the researchers noted that they expand primary care practice capacity and help mitigate shortages.

Despite this help, concerns about workforce availability remain, with fewer trainees choosing primary care, especially in rural areas. As a result, 92% of rural counties were designated primary care health professional shortage areas (HPSAs) in 2023 compared with 83% of nonrural counties, affecting 42 million residents. Specifically, 45% of rural counties had 5 or fewer primary care physicians, including 199 with none at all. On average, there was 1 physician per 2881 rural residents.

The researchers underscored the substantial regional disparities: 97% of rural counties in the South and West were partially or fully designated as primary care HPSAs vs 84% in the Midwest. The ratio of patients to physicians also varied, with the South averaging 3411:1 and the Northeast 1979:1.

Additionally, the researchers noted that limited clinician availability compromises timely access. Consequently, only 4 in 10 working-age rural adults can get same-day or next-day primary care appointments, and about 1 in 3 report easy access to after-hours care. Instead, about 1 in 4 rural adults reported going to the emergency department in the past 2 years for something that could have been handled by their usual doctor, if available. Similarly, 1 in 4 rural adults reported not going to the doctor when needed because of cost, contributing to higher rates of suicide, chronic disease, and poor maternal health.

Although telehealth has the potential to improve access to care, only 2 in 10 rural adults used telehealth for primary care in the past year compared with 3 in 10 nonrural residents. Barriers include limited broadband internet access, inadequate reimbursement, and burdensome clinician licensing requirements, according to the researchers.

Efforts to Strengthen Rural Primary Care Access

Several national initiatives are helping to address these rural primary care challenges. For example, the National Health Service Corps (NHSC) offers loan forgiveness to clinicians who train and work in HPSAs. The researchers noted that the program has helped retain clinicians in these underserved areas, with 84% staying at least 1 year beyond their service period. However, the program could be expanded further, as only 40% of rural counties had at least 1 NHSC primary care clinician in 2023.

Additionally, most rural residents access primary care through Rural Health Clinics (RHCs) or Federally Qualified Health Centers (FQHCs). RHCs are eligible for enhanced reimbursement rates from CMS, while FQHCs are community-based outpatient clinics funded through federal grants and reimbursements that provide services to patients regardless of their ability to pay. In 2021, 90% of rural counties, with a total population of 42 million, had at least 1 such clinic.

Lastly, the Rural Health Transformation Program (RHTP), created under the Working Families Tax Cuts Act, will allocate $50 billion across states by 2030 for workforce development, chronic disease management, digital innovation, and delivery system reforms.2 CMS will oversee fund distribution, with half allocated equally across states and the other half based on state-specific applications. However, the researchers noted that other changes in the law may reduce hospital and health system revenue by up to $87 billion nationally over 10 years, with substantial state variation.1

Strategies to Address Remaining Rural Primary Care Gaps

In addition to the programs already underway, the researchers highlighted several additional steps policymakers and delivery system leaders can take to strengthen rural primary care. One key priority is developing rural-specific financing models. Current payment structures are designed for higher-volume service areas and do not account for the lower patient volume, limited specialty availability, and higher operating costs associated with rural care delivery.

As a result, they underscored the need for payment reform, including enhanced reimbursement rates, bonus payments, upfront infrastructure investments, and payments tied to operational costs to help stabilize rural practices.

The researchers also emphasized the importance of expanding the pipeline of clinicians in rural areas. Strategies include recruiting health care workers locally, incorporating rural rotations into medical school training, increasing opportunities for rural residencies and hands-on learning, and incentivizing clinicians to practice in rural communities through loan repayment programs such as the NHSC.

Lastly, they underscored the need to strengthen rural technology infrastructure. The researchers reiterated that technology can improve access, but telehealth adoption remains limited, largely due to insufficient broadband or satellite internet access.

“Policymakers can invest in broadband infrastructure,” the authors concluded. “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.”

References

1. Horstman C, Shah A. The state of rural primary care in the United States. The Commonwealth Fund. November 17, 2025. Accessed November 17, 2025. https://www.commonwealthfund.org/publications/issue-briefs/2025/nov/state-rural-primary-care-united-states
2. McNulty R. CMS launches $50 billion rural health initiative aiming to close gaps in care quality, access. AJMC®. September 16, 2025. Accessed November 17, 2025. https://www.ajmc.com/view/cms-launches-50-billion-rural-health-initiative-aiming-to-close-gaps-in-care-quality-access