Primary Care Workforce Expanding, but
Mostly in Cities

Laird Harrison

November 02, 2020

The number of primary care providers is increasing per capita in the United States, but they are still disproportionately concentrated in urban centers, researchers say.

The finding may provide some reassurance for those who have worried about a shortage of healthcare workers and whether they will be able to meet the nation's growing burden of chronic diseases.

"Access to primary care doctors is critical to population health and to reduce healthcare disparities in this country," said Donglan Zhang, PhD, an assistant professor of public health at the University of Georgia in Athens.

However, many counties remain underserved, Zhang told Medscape Medical News. The need for primary care in the United States is increasing not only with population growth but because the population is aging, she said.

Zhang and colleagues published the finding in JAMA Network Open .

Many previous reports have warned of a shortage in primary care providers. To examine recent trends in the primary care workforce, Zhang and colleagues obtained data on all the primary care clinicians registered with the Centers for Medicare & Medicaid Services (CMS) from 2009 to 2017.

For the study, the researchers included general practitioners, family physicians and internists without subspecialties, nurse practitioners, and physician assistants. They then compared the number of providers with the number of residents in each county as recorded by the US Census, using urban or rural classifications for each county from the Centers for Disease Control and Prevention (CDC).

Because the US Health Resources and Services Administration (HRSA) defines a primary care 'shortage' as fewer than 1 primary care practitioner per 3,500 people, the researchers focused on this ratio. They found that the number of nurse practitioners and physician assistants was increasing much faster than the number of primary care physicians. This was true especially in rural areas, but the percentage increase for both nurse practitioners and physician assistants was lower in rural areas vs urban.

Table. Primary Care Providers Per 3500 Residents

Year Primary Care Physicians Nurse Practitioners Physician Assistants

Urban Areas

2009, N 2.69 1.65 0.73
2017, N 3.25 3.20 1.20
Change (%) 20.8 93.6 64.9

Rural Areas

2009, N 2.22 1.32 0.65
2017, N 2.54 2.49 0.97
Change (%) 14.3 90.1 49.3


The researchers also found that there were more primary care physicians per capita in counties with higher household incomes, counties with a higher proportion of Asian residents, and counties with a higher proportion of college graduates.

They didn't find a significant association between the median household income and per capita number of nurse practitioners.

They found that counties with a higher proportion of Black and Asian residents had a higher number of nurse practitioners per capita. But they found an opposite association between the proportion of Black residents and the number of physician assistants per capita.

The authors hypothesize that healthcare reform, particularly the passage of the Affordable Care Act in 2010, may explain the recent increase in the primary care workforce. The legislation expanded the number of people with health insurance and provided incentives for primary and preventive care.

Another factor behind the increase in the primary care workforce could be state laws that have expanded the scope of practice for nurse practitioners and primary care providers, she said.

Numbers May Overestimate Available Care

The gap between rural and urban areas could be even wider than this study suggests, Ada D. Stewart, MD, president of the American Academy of Family Physicians, told Medscape Medical News. Many nurse practitioners and physician assistants don't actually practice primary care, but instead assist physicians in other specialties such as orthopedics or general surgery, she said.

"They are part of a team and I don't want to diminish that at all, but especially when we talk about infant and maternal mortality, family physicians need to be there themselves providing primary care," she said. "We're there in hospitals and emergency rooms, and not just taking care of diabetes and hypertension."

In addition, the primary care workforce may have been reduced since the conclusion of the study period (December 31, 2017) as a result of the COVID-19 pandemic forcing some primary care physicians into retirement, Stewart said.

Measures that could help reduce the disparity include a more robust system of teaching health centers in rural counties, higher reimbursement for primary care, a lower cost of medical education, and recruiting more people from rural areas to become physicians, Stewart said.

Telehealth can enhance healthcare in rural areas, but many people in rural areas lack internet or cellular service, or don't have access to computers. "We don't want to create another healthcare disparity," she said.

And physicians can get to know their patients' needs better in a face-to-face visit, she said. "Telehealth does have a place, but it does not replace that person-to-person visit."

This study was funded by National Institute on Minority Health and Health Disparities. Zhang and Stewart have disclosed no relevant financial relationships.

JAMA Netw Open. Published online October 28, 2020. Full text

Laird Harrison writes about science, health and culture. His work has appeared in national magazines, in newspapers, on public radio and on websites. He is at work on a novel about alternate realities in physics. Visit him at or follow him on Twitter: @LairdH.

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