{
  "study": {
    "slug": "care-deserts-2026",
    "title": "America's care deserts are rural: two-thirds of U.S. health-care shortage areas",
    "standfirst": "Two-thirds of America's active health-care shortage areas are rural: 13,999 of the 21,133 designated Health Professional Shortage Areas — 66.2% — sit in rural communities, against 6,069 non-rural ones. The rural skew holds across primary care (66.0%), mental health (65.3%), and dental health (67.4%) alike, spanning 25,281 federal designations in 60 jurisdictions.",
    "desk": "access",
    "article_type": "Original Research",
    "published": "2026-06-14",
    "issue": 70,
    "doi": "10.5072/fonteum/care-deserts-2026",
    "url": "https://fonteum.com/research/care-deserts-2026",
    "methodology_version": "care-deserts/v1"
  },
  "data_as_of": "2026-06-14",
  "datasets": [
    {
      "slug": "hrsa-hpsa",
      "name": "HRSA HPSA",
      "publisher": "HRSA — Health Professional Shortage Areas",
      "upstream_url": null
    }
  ],
  "key_findings": [
    {
      "number": "66.2%",
      "finding": "of the 21,133 designated U.S. Health Professional Shortage Areas are rural — 13,999 of them — against 6,069 non-rural and 942 partially rural designations",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "25,281",
      "finding": "active federal shortage-area designations cover 60 U.S. states and jurisdictions: 21,133 HPSAs (primary care, mental health, dental) plus 4,148 Medically Underserved Areas and Populations",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "34.6%",
      "finding": "of designated HPSAs carry a shortage score of 18 or higher — 7,314 of 21,133 — the most-severe band on HRSA's 0-to-26 scale, where a higher score means a deeper unmet need",
      "dataset": "hrsa-hpsa"
    },
    {
      "number": "1,623",
      "finding": "designated HPSAs sit in California, the most of any state, ahead of Texas (1,111) and Alaska (988) — but Alaska's are almost entirely rural, the clearest single-state care desert",
      "dataset": "hrsa-hpsa"
    }
  ],
  "faqs": [
    {
      "q": "What is a health-care 'care desert' in federal data?",
      "a": "It is an area or population the federal government has formally designated as having too few clinicians. HRSA maintains two designation systems: Health Professional Shortage Areas (HPSAs), scored for primary care, mental health, and dental health, and Medically Underserved Areas and Populations (MUA/MUP). As of the 2026-06-14 snapshot there are 25,281 active designations — 21,133 HPSAs and 4,148 MUA/MUP — across 60 U.S. states and jurisdictions."
    },
    {
      "q": "How many U.S. health-care shortage areas are rural?",
      "a": "Two-thirds of them. Of the 21,133 designated HPSAs, 13,999 (66.2%) are rural, against 6,069 non-rural, 942 partially rural, and 123 of unknown rurality. The rural share barely moves by care type: 66.0% of primary-care HPSAs, 65.3% of mental-health HPSAs, and 67.4% of dental HPSAs are rural."
    },
    {
      "q": "Which states have the most shortage areas?",
      "a": "California carries the most designated HPSAs at 1,623, followed by Texas (1,111), Alaska (988), Missouri (925), and Michigan (793). Raw counts track state size and land area more than they track severity — Alaska's 988 designations are almost entirely rural and are the clearest example of a statewide care desert."
    },
    {
      "q": "Is mental-health access worse than primary-care access?",
      "a": "By count, primary care has slightly more designated HPSAs (7,666) than mental health (6,413) or dental health (7,054). By severity the order flips: the average mental-health HPSA scores 16.36 and the average dental HPSA 16.53, both above primary care's 15.09 on HRSA's 0-to-26 scale. So mental-health and dental shortages are designated less often but, where designated, tend to be rated as deeper."
    },
    {
      "q": "What does a HPSA score mean?",
      "a": "HRSA assigns each HPSA a score from 0 to 26 (mental health tops out at 25); a higher score means a more severe shortage and a higher priority for placing National Health Service Corps clinicians. In this snapshot, 7,314 of 21,133 designated HPSAs — 34.6% — score 18 or higher, the most-severe band, and the median designated HPSA scores 16 to 17."
    },
    {
      "q": "Does a shortage designation name specific clinics or doctors?",
      "a": "No. A HPSA or MUA/MUP designation describes a place or a population group, not a provider. This study is entirely state- and aggregate-level: it counts and groups designations and never names, ranks, or scores any individual clinic, facility, or clinician."
    },
    {
      "q": "Can I reproduce these figures?",
      "a": "Yes. Every number aggregates the public hrsa_shortage_areas table (47,201 rows, of which 25,281 carry status 'Designated') from HRSA's data.hrsa.gov download files, snapshot 2026-06-14. The exact SQL — the rural share, the per-discipline and per-state rollups, and the severity bands — is published in the reproducibility block below."
    }
  ],
  "citation": {
    "apa": "Fonteum Research. (2026, June 14). America's care deserts are rural: two-thirds of U.S. health-care shortage areas. Fonteum Research, Issue 70. https://doi.org/10.5072/fonteum/care-deserts-2026",
    "url": "https://fonteum.com/research/care-deserts-2026"
  },
  "reproducible_sql": "-- America's care deserts — fully reproducible query.\n--\n-- Question: of the areas the federal government has formally designated as\n-- short of clinicians, how many are rural, how severe are they, and where do\n-- they concentrate? We measure, over the ACTIVE (status = 'Designated')\n-- universe, the rural share of HPSAs overall and by discipline, the national\n-- designation totals, the HPSA score-severity distribution, and the per-state\n-- ranking. The lead figure is the rural share of designated HPSAs (66.2%).\n--\n-- Source:\n--   public.hrsa_shortage_areas — HRSA shortage-area designations, unified from\n--     the data.hrsa.gov download files:\n--       BCD_HPSA_FCT_DET_PC.csv  (Primary Care HPSAs)\n--       BCD_HPSA_FCT_DET_MH.csv  (Mental Health HPSAs)\n--       BCD_HPSA_FCT_DET_DH.csv  (Dental Health HPSAs)\n--       MUA_DET.csv              (Medically Underserved Areas / Populations)\n--     Snapshot 2026-06-14. 47,201 rows across all statuses; public, read-only. License: US-Government-Works (17 U.S.C. §105).\n--     methodology_version = 'hrsa-shortage-areas/v1'.\n--\n-- Universe: this study counts only rows whose status is 'Designated' — the\n--   designations actually in force (25,281 rows). Withdrawn (18,931) and\n--   Proposed-For-Withdrawal (2,989) rows are excluded. Every designation\n--   carries a distinct designation_id, so no row is double-counted:\n--   count(*) = count(distinct designation_id) = 25,281 over the universe.\n--\n-- These are simple counts over a 47k-row table, so every figure is EXACT as of\n-- the snapshot, not estimated.\n\n-- ============================================================================\n-- (1) Headline: rural share of designated HPSAs, overall and by discipline.\n--     The all-HPSA rural share (66.2%) is the lead figure.\n-- ============================================================================\nSELECT\n  coalesce(discipline, 'ALL HPSA')                                   AS discipline,\n  count(*)                                                           AS designated,\n  count(*) FILTER (WHERE rural_status = 'Rural')                     AS rural,\n  count(*) FILTER (WHERE rural_status = 'Non-Rural')                 AS non_rural,\n  count(*) FILTER (WHERE rural_status = 'Partially Rural')           AS partially_rural,\n  round(100.0 * count(*) FILTER (WHERE rural_status = 'Rural')\n        / count(*), 1)                                               AS rural_pct\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated' AND designation_kind = 'hpsa'\nGROUP BY ROLLUP (discipline)\nORDER BY discipline;\n--  Primary Care    7,666  rural 5,058   66.0\n--  Mental Health   6,413  rural 4,189   65.3\n--  Dental Health   7,054  rural 4,752   67.4\n--  ALL HPSA       21,133  rural 13,999  non_rural 6,069  partially 942   66.2\n--  (123 designated HPSAs carry rural_status='Unknown' — reported separately,\n--   not reassigned. 13,999 + 6,069 + 942 + 123 = 21,133.)\n\n-- ============================================================================\n-- (2) The MUA/MUP layer + the combined two-system total.\n-- ============================================================================\nSELECT\n  designation_kind,\n  count(*)                                              AS designated,\n  count(*) FILTER (WHERE rural_status = 'Rural')        AS rural,\n  round(100.0 * count(*) FILTER (WHERE rural_status = 'Rural')\n        / count(*), 1)                                  AS rural_pct\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated'\nGROUP BY ROLLUP (designation_kind)\nORDER BY designation_kind;\n--  hpsa      21,133  rural 13,999  66.2\n--  mua_mup    4,148  rural  2,432  58.6\n--  TOTAL     25,281  rural 16,431  65.0   (every state + DC + territories = 60)\n\n-- ============================================================================\n-- (3) National designation totals by system + discipline (composition).\n-- ============================================================================\nSELECT\n  designation_kind,\n  discipline,\n  count(*) AS designated\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated'\nGROUP BY designation_kind, discipline\nORDER BY designated DESC;\n--  hpsa     Primary Care   7,666\n--  hpsa     Dental Health  7,054\n--  hpsa     Mental Health  6,413\n--  mua_mup  (null)         4,148\n--  total designations 25,281 across 60 jurisdictions\n\n-- ============================================================================\n-- (4) Severity — HPSA score distribution (0-26 scale; higher = deeper need).\n--     34.6% of designated HPSAs score 18+, the most-severe band.\n-- ============================================================================\nSELECT\n  count(*)                                              AS designated_hpsa,\n  count(*) FILTER (WHERE score >= 18)                   AS score_18_plus,\n  count(*) FILTER (WHERE score BETWEEN 14 AND 17)       AS score_14_17,\n  count(*) FILTER (WHERE score BETWEEN 1 AND 13)        AS score_1_13,\n  count(*) FILTER (WHERE score = 0)                     AS score_0,\n  round(100.0 * count(*) FILTER (WHERE score >= 18)\n        / count(*), 1)                                  AS pct_18_plus\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated' AND designation_kind = 'hpsa';\n--  designated 21,133 · 18+ 7,314 · 14-17 8,761 · 1-13 5,043 · 0 15 · pct_18+ 34.6\n\n-- Mean / median score by discipline (severity order flips vs raw count):\nSELECT\n  discipline,\n  count(*)                                                       AS designated,\n  round(avg(score), 2)                                           AS mean_score,\n  percentile_cont(0.5) WITHIN GROUP (ORDER BY score)             AS median_score,\n  max(score)                                                     AS max_score\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated' AND designation_kind = 'hpsa'\nGROUP BY discipline\nORDER BY mean_score DESC;\n--  Dental Health  7,054  mean 16.53  median 17  max 26\n--  Mental Health  6,413  mean 16.36  median 17  max 25\n--  Primary Care   7,666  mean 15.09  median 16  max 25\n\n-- ============================================================================\n-- (5) Where the deserts concentrate — top states by designated HPSAs.\n-- ============================================================================\nSELECT\n  state,\n  count(*) FILTER (WHERE discipline = 'Primary Care')   AS primary_care,\n  count(*) FILTER (WHERE discipline = 'Mental Health')  AS mental_health,\n  count(*) FILTER (WHERE discipline = 'Dental Health')  AS dental,\n  count(*)                                              AS total_hpsa\nFROM public.hrsa_shortage_areas\nWHERE status = 'Designated' AND designation_kind = 'hpsa'\nGROUP BY state\nORDER BY total_hpsa DESC\nLIMIT 7;\n--  CA  559  518  546  1,623\n--  TX  390  386  335  1,111\n--  AK  330  330  328    988   (almost entirely rural — statewide care desert)\n--  MO  340  259  326    925\n--  MI  274  257  262    793\n--  IL  295  184  250    729\n--  KY  245  210  246    701\n\n-- ============================================================================\n-- (6) Universe reconciliation — status split + distinct-id check.\n-- ============================================================================\nSELECT\n  count(*)                                              AS all_rows,\n  count(*) FILTER (WHERE status = 'Designated')         AS designated,\n  count(DISTINCT designation_id)\n    FILTER (WHERE status = 'Designated')                AS distinct_designated_ids,\n  count(*) FILTER (WHERE status = 'Withdrawn')          AS withdrawn,\n  count(*) FILTER (WHERE status = 'Proposed For Withdrawal') AS proposed_withdrawal,\n  count(DISTINCT state) FILTER (WHERE status = 'Designated') AS jurisdictions\nFROM public.hrsa_shortage_areas;\n--  all_rows 47,201 · designated 25,281 · distinct_designated_ids 25,281\n--  withdrawn 18,931 · proposed 2,989 · jurisdictions 60\n--  (25,281 + 18,931 + 2,989 = 47,201; designated = distinct designation_id,\n--   so no duplicate inflation.)",
  "license": "U.S. Government Works (federal sources; 17 U.S.C. §105)",
  "generated_by": "Fonteum — https://fonteum.com",
  "notes": "Aggregate, source-traced figures frozen to the snapshot above. Reproduce by running reproducible_sql against the cited federal dataset; no per-entity records are included."
}