Nurses and Access to Primary Care

Given current concerns about a shortage of primary care health professionals, the committee paid particular attention to the role of nurses, especially APRNs,2 in this area. Today, nurse practitioners (NPs), together with physicians and physician assistants, provide most of the primary care in the United States. Physicians account for 287,000 primary care providers, NPs for 83,000, and physician assistants for 23,000 (HRSA, 2008; Steinwald, 2008). While the numbers of NPs and physician assistants are steadily increasing, the numbers of medical students and residents entering primary care have declined in recent years (Naylor and Kurtzman, 2010). The demand to build the primary care workforce, including APRNs, will grow as access to coverage, service settings, and services increases under the ACA. While NPs make up slightly less than a quarter of the country’s primary care professionals (Bodenheimer and Pham, 2010), it is a group that has grown in recent years and has the potential to grow further at a relatively rapid pace.

The Robert Wood Johnson Foundation (RWJF) Nursing Research Network commissioned Kevin Stange, University of Michigan, and Deborah Sampson, Boston College, to provide information on the variation in numbers of NPs across the United States. Figures 3-1 and 3-2, respectively, plot the provider-to-primary care doctor of medicine (MD) ratio for NPs and physician assistants by county for 2009.3 The total is calculated as the population-weighted average for states with available data. Between 1995 and 2009, the number of NPs per primary care MD more than doubled, from 0.23 to 0.48, as did the number of physician assistants per primary care MD (0.12 to 0.28) (RWJF, 2010c). These figures suggest that it is possible to increase the supply of both NPs and physician assistants in a relatively short amount of time, helping to meet the increased demand for care.

In addition to the numbers of primary care providers available across the United States and where specifically they practice, it is worth noting the kind of care being provided by each of the primary care provider groups. According to the complexity-of-care data shown in Table 3-1, the degree of variation among primary care providers is relatively small. Much of the practice of primary care—whether provided by physicians, NPs, physician assistants, or certified nurse midwives (CNMs)—is of low to moderate complexity.


APRNs include nurse practitioners (NPs), certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). When the committee refers to NPs, the term denotes only NPs.


To get a sense of the size and proportion of the NP workforce across the country, Stange and Sampson computed the ratio of the total number of licensed NPs to the total number of primary care MDs, physician assistants, and NPs in a given area. The physician assistant share was computed similarly. These computations are for proportion and growth analysis purposes only; they are not to suggest that all NPs or physician assistants are providing primary care.

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