Governors’ Policy Actions in Rural Health Workforce

Rural Health Transformation Program Insights

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Governors play a critical role in shaping the health workforce, using levers such as budget proposals, executive authority, and cross-agency coordination to recruit, train, and regulate workers. States face workforce shortages, particularly in rural areas, which reduce access to healthcare, impact health outcomes and harm local economies. The Health Resources and Services Administration (HRSA) estimates 106 million people live in a primary care Health Professional Shortage Area (HPSA), and rural communities account for 63.6% of these HPSAs. HRSA projects a shortage of 141,160 physicians by 2038, with greater gaps in rural areas. These workforce challenges require coordinated policy responses involving stakeholders across government and rural communities.

The Rural Health Transformation Program (RHTP) offers states the opportunity to invest in their rural health workforces through innovative approaches. In their applications, governors summarized strategies their states will pursue to strengthen the rural health workforce (note that some of these proposals are under CMS review and are subject to change). This brief, part of NGA's RHTP memo action series, outlines key policy actions across several areas: career pathways, education and training, recruitment and retention, and licensure and scope of practice.

Career Pathways, Education and Training

Career pathway programs support worker advancement through education and training models. Studies show that career pathways programs can meaningfully increase educational progress and employment in targeted industries.

High School Partnerships for Early Exposure to Health Careers

Early exposure to health careers may increase the likelihood of entering the healthcare field, and states are investing in these experiences for students.

• Minnesota plans to increase high school student exposure to health care careers by expanding Health Occupations Students of America (HOSA) chapters, which provide career opportunities and leadership development for health sciences students, and Scrubs Camps, which offer workshops, simulations, and health care facility field trips. This work will focus on high-need, entry-level roles, such as community health workers, emergency medical technicians, community paramedics and nursing assistants.
• Mississippi will target high school students through education, mentorship, and experiential opportunities in the nursing and allied health professions.

Career Pathways

Clear tracks for career advancement can support health workforce retention and grow needed skills and expertise.

• California is planning to develop healthcare career pathways based on workforce gaps identified through a new mapping and planning tool. This information will also inform efforts to expand training and education capacity as well as "train-the-trainer" programs to cross-train and increase skills for medical and allied staff.
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  Maryland will invest in its registered apprenticeship programs to introduce additional healthcare offerings in rural communities. The state will also expand apprenticeships for certified nursing assistants, alcohol and drug counselors, community health workers, and other priority roles.

Rural Education and Training Opportunities

Family physicians who train in rural areas are more likely to continue working in these communities, and states are expanding capacity for rural training programs to grow this workforce along with other health workers. States may consider partnering with Area Health Education Centers (AHECs) on these efforts.

• Arizona plans to invest in the Rural Nursing and Allied Professionals Education Program to hire additional nursing and allied professional teachers at community colleges in more rural areas. The state will also create new rural clinical rotations and residency slots for priority health care specialties in rural communities.
• Oklahoma will expand rural residency programs for surgery, psychiatry and OBGYN specialties through state medical school and rural health care facility partnerships. The state will also provide startup funding for resident stipends, housing and preceptor support so additional rural clinics and hospitals can host residents.
• Tennessee will extend a rural dental workforce pilot, add clinicians and dental suites, and expand preventive oral health services to reduce emergency department visits and improve oral health access in Dental HPSAs.

Recruitment and Retention

Recruitment policies bring people into healthcare fields in rural areas, while retention policies keep these workers and their expertise in these communities. States are strategizing ways to ensure worker supply meets demand and that these workers are set up for success with the proper support.

Recruitment Incentives

Governors are building on existing recruitment initiatives like scholarship and loan repayment programs by directing RHTP funds toward supports that will draw qualified workers to rural areas.

• Montana plans to incentivize healthcare workers to move to rural communities by offering relocation support as well as wellness and resilience programs to prevent burnout and isolation.
• Pennsylvania will treat Emergency Medical Services (EMS) workers as a professional provider workforce by providing rural service bonuses, training opportunities, tuition reimbursement for career advancement and mental health mentorship.

Administrative Burden Reduction

States are investing in strategies to streamline administrative burden and reduce provider burnout.

• North Carolina plans to create regional rural training hubs by coordinating with higher education institutions, hospitals and other key partners. The state will build culturally responsive health career pathway programs with a focus on tribal communities to increase recruitment and retention in these communities.
• Utah will explore using financial incentives and on-the-job training to increase provider rural placement and retention. The state also plans to support rural health providers practicing at the top of their license.

Licensure and Scope of Practice

Health workforce scope of practice and licensure policies define activities these workers can engage in and requirements for their licensure, impacting worker mobility and supply.

Interstate Licensure Compacts

Many states included plans to join interstate licensure compacts in their RHTP applications to offer health care workers a faster way to get licensed to work across state lines or in a new state. State legislation is usually required to participate in these compacts.

• Alabama Governor Kay Ivey recently signed legislation allowing the state to join the physician assistant (PA) licensure compact, streamlining the state licensure process for PAs moving to Alabama.
• Alaska plans to pursue joining the physician, nursing, EMS, psychology and PA licensure compacts.

Scope of Practice Changes

States are considering changes to healthcare provider practice authority to expand worker capacity and flexibility to meet patient needs while maintaining appropriate safeguards for quality care.

• Oregon plans to explore scope of practice changes to give pharmacists additional authority, including drug administration, laboratory testing and prescribing authority. This is part of a wider effort to expand pharmacy services to meet health care demand across the state.
• Vermont will expand scope of practice and develop a reimbursement model for paramedics to triage patients based on the severity of their condition and treat people in the community. This change will allow these workers to provide care in patients' homes without needing to be transported to emergency departments.

Governors are strengthening their rural health workforce by advancing new solutions and expanding successful existing programs using RHTP funds. With older adults growing at a faster rate than any other age group in the United States, states will see increasing demand for health care while more people leave the workforce for retirement. Through innovative approaches that offer opportunities to join the health workforce, support worker well-being, and balance safety and flexibility in worker regulations, governors will continue to strengthen the health workforce. The National Governors Association remains ready to support states and circulate best practices as they implement these programs and transform their rural health care systems.

This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $1,585,000 with 100 percent funded by HRSA/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the U.S. Government.

This publication was prepared by Anna Heard with the NGA Center for Best Practices.