The Most Rural Counties Have the Fewest Health Care Services Available

Access to health care depends on the three pillars of affordability, availability, and willingness to seek care. USDA, Economic Research Service (ERS) researchers compared the availability of health care based on a county’s degree of urbanization. They found that during 2017–19 residents of the most rural counties may have had more difficulty finding and using health care services than residents living in metropolitan areas or more rural counties with population hubs. The most rural counties had fewer health care facilities and were more likely to have health professional shortage areas, the research showed.

Counties that are part of, or economically linked to, large urban areas are “metropolitan.” “Nonmetropolitan” counties are subdivided into “micropolitan” and “noncore” counties. Micropolitan refers to counties with smaller urban areas and outlying counties that are economically linked to them. Noncore counties are all other counties and are the most rural. ERS researchers examined health care resource availability by looking at three factors: the number of medical providers for every 10,000 residents, the number of beds in medical facilities for every 10,000 residents, and the share of counties with health care facilities.

ERS researchers found that in 2017, metropolitan counties had the greatest availability of medical professionals, with an average of 6.1 primary care physicians and 4.1 dentists for every 10,000 residents. In noncore counties, the average was 4.4 primary care physicians and 2.5 dentists for every 10,000 residents. However, metropolitan counties had the fewest beds per 10,000 residents, while sparsely populated noncore counties had the most (see table below).

Researchers found evidence that medical resources to treat residents in nonmetropolitan areas were concentrated in a few, probably more populated, locations. Residents in micropolitan counties—which contain rural population hubs—had the greatest availability of hospitals. The share of micropolitan counties with a short-term general hospital was the largest of the county types in 2017 at 89 percent. In addition, micropolitan counties had higher bed-to-population ratios than metropolitan counties.

Although noncore counties had the highest bed-to-population ratios (owing in part to their sparse populations), they were also less likely to have medical facilities available. In 2017, the share of noncore counties with hospitals was 72 percent, compared with 89 percent for micropolitan and 82 percent for metropolitan. The share with skilled nursing facilities was 83 percent, compared with 95 percent for micropolitan and 96 percent for metropolitan. This suggests people living in more remote locations needed to travel farther to access health care.

ERS researchers also examined health professional shortage areas (HPSA). As identified by the U.S. Department of Health and Human Services, a health professional shortage area is where there are too few practitioners to provide adequate care for area residents. These areas do not necessarily follow county boundaries. They can be as small as a single site in a county (such as a prison), cover an entire county, or be composed of multiple counties. HPSAs also take into account location characteristics such as distance to the nearest provider and whether residents have unusually high health care needs, so some shortage areas may exceed the minimum provider-to-population threshold.

In 2019, more counties in the United States were completely covered by mental health HPSAs (meaning the entire county lacked sufficient mental health care services) than any other type of health professional shortage, while the fewest counties were completely covered by a dentist shortage area. Noncore areas—the least densely populated rural areas—had the most counties completely covered by HPSAs of any type. Forty percent of noncore counties were completely covered by primary care shortage areas, compared with 16 percent for metropolitan counties. Moreover, 24 percent of noncore counties experienced entire-county shortages of dentists, compared with 8 percent for metropolitan counties. More than four-fifths (81 percent) of noncore counties were completely covered by mental health professional shortages, compared with 36 percent for metropolitan areas.

Health care was less available in the most rural U.S. counties in 2017 and 2019

	Metropolitan counties	Nonmetropolitan counties
		Micropolitan	Noncore
Share of counties with facilities (percent, 2017)
Hospital	82.1	88.9	72.2
Short-term general hospital	80.5	88.8	71.2
Skilled nursing facility	96.1	94.8	83.1
Mean bed-to-population ratio (per 10,000 residents, 2017)
Hospital	25.0	27.8	35.2
Short-term general hospital	20.2	24.5	32.7
Skilled nursing facility	58.2	75.8	96.1
Mean provider-to-population ratio (per 10,000 residents, 2017)
Total physicians	21.2	13.8	7.1
Primary care physicians	6.1	5.4	4.4
Dentists	4.1	3.6	2.5
Share of counties completely covered by HPSAs (percent, 2019)
Primary care shortage	16.3	16.8	40.4
Dentist shortage	7.5	10.8	24.0
Mental health shortage	36.0	70.0	80.6
Notes: Metropolitan counties are part of an urban area of at least 50,000 residents or are tied to one through commuting. Nonmetropolitan counties are not part of a metropolitan area and are subdivided into micropolitan counties and noncore counties. Micropolitan counties are part of an urban area of between 10,000 and 49,999 residents or are tied to one through commuting. Noncore counties are all remaining nonmetropolitan counties. Short-term general hospitals provide general medical and surgical care to patients who usually stay less than 30 days. Skilled nursing facilities provide inpatient medical, nursing, or rehabilitative care at a level below that of a hospital. Only Medicare-certified skilled nursing facility beds are included in the table. Physicians include doctors of medicine and doctors of osteopathy. Primary care physicians include general/family medicine, general pediatrics, and general internal medicine. HPSAs are health professional shortage areas. Their population-to-provider ratio is below a threshold needed to adequately care for residents, as identified by the U.S. Department of Health and Human Services. HPSA shares indicate the percentage of counties whose entire area was part of HPSAs. Obstetricians and gynecologists are included in the definition of primary care physicians for HPSAs. Sources: USDA, Economic Research Service using U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Workforce, 2018–19 Area Health Resources File.