Guam has 1 psychiatrist in the Medicare clinician directory. One. Across a jurisdiction of nearly 160,000 people, the entire federal directory records a single psychiatrist, yielding a ratio of 0.07 per 100,000 clinicians against a total directory population of 1,478,578. That number is not a rounding artifact. It is the floor.

The Three Jurisdictions That Fall Off the Map

Only three jurisdictions fall below 1 psychiatrist per 100,000 clinicians in the Medicare directory, and all three are U.S. territories in the Pacific or Caribbean.

Every U.S. state clears the threshold. Wyoming, the lowest-ranked state, has 44 psychiatrists listed, or 2.98 per 100,000 clinicians. That's 42 times the rate recorded for Guam. For residents of these territories, the directory doesn't describe a thin safety net. It describes something closer to an absence.

The practical consequence is direct: a Medicare beneficiary in Guam seeking a directory-listed psychiatrist has, by the data, one option. Referral networks, telehealth arrangements, and off-directory providers may exist, but the federal directory, which is the primary tool patients and care coordinators use to locate in-network specialists, shows a single name.

Rural States Have a Different Problem, and It's Structural

The territory gap is extreme, but the rural-state picture reveals a different kind of scarcity, one that runs across specialties rather than concentrating in a single one.

Rural-heavy states (Wyoming, Montana, North Dakota, South Dakota, and Vermont) show a primary care to specialist ratio of 0.1139. Urban-proximate states (California, New York, Texas, and Florida) show a ratio of 0.1704. That gap, roughly 50 percentage points wider in urban states, means rural clinician directories are proportionally more primary-care-heavy, not because primary care is abundant there, but because specialist representation is thin.

The raw counts make this concrete. Rural-heavy states together list 2,728 primary care clinicians and 23,960 specialists. Urban-proximate states list 63,331 primary care clinicians and 371,563 specialists. The urban group has roughly 23 times as many specialists, but only about 15 times as many primary care providers. Specialists concentrate in cities at a faster rate than primary care does, which means the rural-to-urban gap widens as you move up the acuity ladder.

For a patient in Wyoming needing a subspecialty referral, that ratio matters. Primary care providers in rural directories are already stretched. When the specialist column is proportionally thinner than in urban markets, the referral pipeline gets longer, not just geographically but numerically.

What the Directory Can and Can't Tell Us

Wyoming's 44 listed psychiatrists clear the 1-per-100,000 threshold, but that number raises a question the directory data alone can't close: are those 44 clinicians distributed across the state's rural ZIP codes, or are they concentrated in Cheyenne and Casper? A statewide count that clears a threshold can still leave most of the state's geography uncovered.

The same logic applies to the territory numbers, in reverse. Guam's single listed psychiatrist represents the worst-case scenario in the directory, but the directory may undercount providers who treat Medicare patients without formal directory enrollment. The gap between directory presence and actual access is real, and it's likely larger in under-resourced jurisdictions where enrollment incentives are weaker.

What the directory does capture precisely is the formal, searchable infrastructure that patients and care coordinators rely on. By that measure, three U.S. jurisdictions have effectively no psychiatric coverage, and rural states show a structural specialist deficit that compounds as care complexity increases. You can't solve a shortage you haven't mapped, and the map here is unambiguous about where the gaps are deepest.