A woman pushes her elderly father in a wheelchair outside.

Rural America Is Aging—Without Enough Care Workers

Faced with a deficit of nursing assistants and home health aids, rural areas lack the workforce they need for people to age in place, new research finds.

Home health aides and nursing assistants are crucial for helping an aging population stay in their homes instead of moving to a nursing home or other facility. Yet new research finds rural areas not only have more older residents, but lack the workforce needed to help them “age in place.”1

Rural Areas Have Fewer Workers to Support Aging in Place

Compared to urban areas, rural areas have nearly 35% fewer home health aides for their aging populations, finds new research by Janette Dill and coauthors at the University of Minnesota. There are only 32.8 home health aides per 1,000 older adults in rural areas, compared with 50.4 in urban areas, the team determined.

Further, rural areas have just 20.9 nursing assistants per 1,000 older adults compared with 25.3 in urban areas—a 17% gap. These differences underscore geographic inequities in the availability of care, which may constrain who is able to age in place.

The researchers point to several reasons why rural areas may have fewer direct care workers, including lower wages, job quality issues, and a lack of investment in the direct care workforce, such as job training programs and financial incentives for workers.

Population aging also plays an important role in the caregiving gap and can help explain regional differences. Regionally, New England, home to some of the oldest states in the country, has among the lowest ratios of home health aides and nursing assistants—in both rural and urban areas (see figure). “It is likely that population demographics are driving their direct workforce supply,” Dill and coauthors note. To address such shortages, some states have initiated efforts to increase the size of the direct care workforce, including wage increases, health insurance options, and free and accessible training.

Figure. New England States Have the Fewest Care Workers for Older Adults

Note: A list of the states in each census division is available on the Census Bureau’s website: https://www.census.gov/programs-surveys/economic-census/guidance-geographies/levels.html#par_textimage_34.
Source: Janette Dill et al., “Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas,” Journal of Applied Gerontology 42, no. 8 (2023). https://doi.org/10.1177/07334648231158482.


The Pacific and West South Central states have the largest rural-urban gaps in the ratio of home health aides to older adults. The West North Central states stand out because of the higher ratios of nursing assistants to older adults in both rural and urban areas.

Family and Friends Are Filling in the Caregiving Gaps 

The deficit of direct care workers in rural areas increases the importance of unpaid care from family and friends. Vicki Freedman (University of Michigan) and coauthors describe how U.S. demographic and social trends add uncertainties to our understanding of the future of family caregiving to older adults.2

The United States has experienced profound demographic changes—in marriage, partnering, fertility and family size, stepfamilies, and kinlessness—the authors note. These trends affect the number and type of family members who can care for Americans as they age.

But simply having kin doesn’t mean that care will be provided. Freedman and coauthors point out that the factors that help predict whether family and friends will help care for the older adults in their lives have also been changing.

Proximity and living arrangements are important factors, especially in rural parts of the country, the authors note. Paid work obligations, intergenerational relationships, and attitudes about caregiving also contribute to decisions about who provides care, as does access to alternatives such as paid or residential care.

To better understand how demographic and social trends in the United States will influence the future of family caregiving, Freedman and colleagues call for research on “the processes by which caregiving networks form and change and to increasingly diverse and complex kin connections.”

Policies Can Help More People Age in Place

State and policies and approaches matter tremendously for successful aging in place. Chanee Fabius (Johns Hopkins Bloomberg School of Public Health) and coauthors find that the environmental context can improve or worsen the care experiences of older people with disabilities.3

Using data from the National Health and Aging Trends Study, Fabius and team found that older adults with disabilities more often have unmet care needs when they live in neighborhoods with higher rates of poverty and public assistance and less social cohesion. In addition, lower wages for and limited paid family leave for direct care workers restrict older adults’ ability to do the activities they enjoy. The physical environment—including a lack of affordable housing—can also reduce older adults’ feelings of well-being. Such hyperlocal factors are the products of policies and practices, yet have a direct impact on how well older adults age in place, the authors add.

Dill offers concrete policy solutions to improve the immediate supply of direct care workers, such as increasing investments in training and paying higher wages. States like Wisconsin, which provides free training and career placement, or Colorado and North Carolina, which used American Rescue Plan Funds to boost wages, offer examples.4 Making it easier for short-staffed in rural areas to apply for funding to support their workforce could also help reduce urban-rural gaps in the availability of care.

As older Americans live longer and choose to age in place, ensuring that those who help them are secure and supported—whether they are paid professionals or unpaid family members—will be a priority in the years to come.


  1. Janette Dill et al., “Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas,” Journal of Applied Gerontology 42, no. 8 (2023).
  2. Vicki Freedman et al. “The Changing Demography of Late-Life Family Caregiving: A Research Agenda to Understand Future Care Networks for an Aging U.S. Population,” The Gerontologist 64 (2024).
  3. Chanee Fabius et al., “The Role of Person- and Family-Oriented Long-Term Services and Supports,” Milbank Quarterly 101, no. 4 (2023): 1076–1138.
  4. Janette Dill et al., “Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas,” Rural Health Research Center Policy Brief. November 2022.