NP workforce growth is outpacing physicians, but access gains remain uneven
The nation’s nurse practitioner workforce is expanding at a pace that dwarfs physician growth, yet the raw head count tells only part of the story. A new Milbank Memorial Fund analysis argues that faster growth does not automatically translate into better primary care access, especially when training standards vary, workforce data are incomplete and many NPs move into specialties after graduation.
The report projects nearly 11% annual NP workforce growth from 2023 through 2030, compared with 1.1% for physicians. Early-career clinicians are driving much of that expansion: the number of NPs younger than 40 rose 389% from 2010 to 2023. Those numbers sound like a solution to access problems on paper, but the report makes a sharper point. Workforce expansion is only useful if clinicians end up where patients need them most.
Growth is not access.
The primary care pipeline leaks before patients ever see the benefit
About 90% of NPs train in primary care, yet fewer than half appear to practice there. Recent estimates place the share working in primary care at 31% to 45%, a gap large enough to change how policymakers should interpret workforce statistics. Rising demand and stronger compensation in acute care, psychiatry and other specialties have pulled many primary care-trained NPs away from the settings they originally prepared for.
That drift has direct implications for underserved communities. Research cited in the report found that NPs work in 66% of primary care practices in the most disadvantaged communities, compared with 33% in the least disadvantaged. In other words, the profession is already doing real work where shortages are most painful. The unanswered operational problem is how to keep that supply from leaking into higher-paying or less demanding settings before it reaches patients in primary care.
Postgraduate residency and fellowship programs have emerged as one answer. These programs provide one to two years of supported transition to practice, often in safety-net settings where the work is complex and the pressure is high. O’Reilly-Jacob said those programs have been associated with lower burnout and better retention in underserved communities. Clinically, that makes sense: structured mentoring and supervised ramp-up can blunt the shock of moving from classroom learning to the volume, acuity and social complexity of real-world primary care.
Training standards vary widely across programs and certifiers
Distance-based NP programs have widened access for nurses who cannot relocate because of caregiving, employment or financial pressures. That shift has also changed the education market. From 2014 to 2024, the share of fully online NP programs rose from 11% to 25%, while fully in-person programs fell from 17% to 6%.
Online instruction itself is not the central problem. The concern centers on a small group of “high-volume, low-touch” programs with near-universal admissions, limited faculty contact and students left to locate and pay for their own preceptors. The largest for-profit NP program graduated 2,129 NPs in 2023, representing 6.4% of all NP graduates that year. Scale alone does not guarantee rigor, and in health professions education, the quality of clinical exposure often matters more than the convenience of the delivery model.
Clinical hour requirements remain uneven as well. Accreditors require 500 hours of direct patient care, while the 2022 National Task Force for Quality Nurse Practitioner Education recommends 750. Some programs are moving voluntarily toward the higher threshold, but the system lacks consistent enforcement. Shannon Idzik said her own research found programs with more than 750 clinical hours were eight times more likely to have a 100% certification pass rate and nearly five times more likely to have a pass rate above 80%.
The practical consequence is hard to ignore. Early certification results for the first six months of this year showed pass rates of 72% for family nurse practitioners and 77% for adult-gerontology primary care NPs. With roughly 30,000 graduates a year and pass rates in the 72% to 80% range, only about 24,000 reach the workforce.
Data gaps make it hard to know where NPs actually practice
One of the report’s sharpest criticisms is that the system does not track the workforce well enough to know whether it is delivering primary care. Medicare claims use a generic NP code that does not separate primary care from specialty practice. Only about half of state boards of nursing directly oversee NP education. Schools can choose among three accreditors, students can choose among competing certification exams, and those choices make consistent national oversight harder to enforce.
Idzik said the system is becoming less consistent, not more. Only one accreditor still requires the National Task Force standards, while one certifier recently moved to 750 hours. For patients, the stakes are obvious: if regulators cannot measure training quality and practice location clearly, policy cannot reliably shape either.
Minnesota already publishes pass rates by institution and NP track, offering one model for greater transparency. The report recommends that states require NP programs to publicly report first-time certification pass rates, the share of instruction delivered online and the number of graduates. It also calls for every state board of nursing to oversee NP education.
Funding shapes whether primary care training can keep pace
When asked which policy lever mattered most, both O’Reilly-Jacob and Hovik Khosrovian chose funding. The contrast with physician training is stark. In 2019, federal Health Resources and Services Administration programs supporting NP education totaled about $69 million. Medicare spent $16.2 billion the following year on graduate medical education for physician residencies.
The funding gap is not just symbolic. It limits the ability to compensate preceptors, recruit them and reward the clinicians who teach in difficult settings. The report suggests state or federal tax incentives for clinicians who serve as NP preceptors. Khosrovian described the imbalance as a driver of outcomes, not a side issue. California’s Song-Brown program illustrates the scale difference: about $3.9 million a year for family NP and PA training grants, compared with $31 million a year for primary care residencies.
California has tried to close some of the information gaps by adding National Provider Identifier numbers to licensing data and expanding its workforce survey to capture primary care practice patterns. The state expects a primary care supply-and-demand model in early 2027. Even there, though, the core issue remains distribution. California has about 48,000 NPs, but the state may be dealing as much with maldistribution as with absolute shortage.
Retention depends on where clinicians train and how they work
Retention data remain thin, but the available numbers suggest that geography matters. In California scholarship and loan repayment programs, retention runs around 50% after five years. Clinicians recruited from and trained in a community are more likely to stay. Those brought in from out of state or from dense urban areas to serve rural communities tend to leave once their obligation ends.
Team-based care may help keep NPs in primary care by reducing burnout and distributing workload across the care team. O’Reilly-Jacob said interprofessional care has been shown to lower burnout when responsibilities are shared, which can improve retention in underserved communities. The barrier is payment. As health systems move away from fee-for-service and toward value-based models, those team-based arrangements become easier to support financially.
The policy debate is not really about choosing speed or quality. It is about whether the country can expand NP supply without weakening the clinical experience that makes primary care practice sustainable. For now, the report leaves one central problem in plain view: the nation is producing more NPs, but it still cannot say with confidence how many are delivering primary care, where they are practicing or how long they stay.