Rural Health: Addressing Barriers to Care

Who Lives in Rural America?

46.1 million people live in rural areas: James C. Davis et al., US Department of Agriculture, Rural America at a Glance: 2022 Edition, 2022

• Note: “Rural” and nonmetropolitan (nonmetro) are used interchangeably in this report and are defined the same on the basis of counties.

Percentage of each state that is rural: US Census Bureau, Urban and Rural, 2020

• Note: Based on most recent census data, 2020.

15% of the US population resides in rural areas: Sally C. Curtin & Merianne Rose Spencer, CDC National Center for Health Statistics, Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019, 2021

Rural population has been increasing: James C. Davis et al., US Department of Agriculture, Rural America at a Glance: 2022 Edition, 2022

Rural residents are older: US Food and Drug Administration, Rural Health, 2021

Rural vs. urban life expectancy: David Clove, Ballard Brief, Healthcare Access Disparities among Rural Populations in the United States, 2023

Rural Health Disparities

Rural residents have a higher rate of dying from several conditions: Sally C. Curtin & Merianne Rose Spencer, CDC National Center for Health Statistics, Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019, 2021

• Note: Standard population refers to age-adjusted distribution of deaths.

Rural residents are also more likely to be at risk for -

• Hypertension: Claudine M. Samanic et al., Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Prevalence of Self-Reported Hypertension and Antihypertensive Medication Use by County and Rural-Urban Classification — United States, 2017, 2020

• Diabetes: Sagar B. Dugani et al., JAMA Network Open, Assessment of Disparities in Diabetes Mortality in Adults in US Rural vs Nonrural Counties, 1999-2018, 2022

• Obesity: Elizabeth A. Lundeen et al., Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Obesity Prevalence Among Adults Living in Metropolitan and Nonmetropolitan Counties — United States, 2016, 2018

• Food insecurity: Feeding America, Hunger in rural communities, 2023

• Poor physical activity: Centers for Disease Control and Prevention, About Rural Health, 2023

• Cigarette smoking: Centers for Disease Control and Prevention, About Rural Health, 2023

Rural health population disparities: Office of Minority Health and Health Equity, Food and Drug Administration, Rural Health, 2022

Barriers to Accessing Care in Rural Communities

People living in rural areas are at greater risk for poor health conditions: Centers for Disease Control and Prevention, About Rural Health, 2023

80% of rural America is medically underserved: Eli Saslow, The Washington Post, ‘Out here, it’s just me’: In the medical desert of rural America, one doctor for 11,000 square miles, 2019

Medically underserved definition: National Center for Advancing Translational Sciences, Underserved group, US Health Services Administration definition, 2023

Rural hospital closures -

• Closures 2005 - Present: The Cecil G. Sheps Center for Health Services Research, University of North Carolina Chapel Hill, Rural Hospital Closures, 2023

• Government relief funds: Nancy Ochieng et al., Kaiser Family Foundation, Funding for Health Care Providers During the Pandemic: An Update, 2022

• Closures and conversions: US Public Health Service, Addressing Health Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce, 2022

• Consolidation, Acquisitions, & Mergers:

  • Claire E. O’Hanlon et al., Health Affairs, Access, Quality, And Financial Performance Of Rural Hospitals Following Health System Affiliation, 2019

  • Arielle Dreher, Axios, ​​Some states encourage hospital mergers while feds cast wary eye, 2023

  • Victoria Bailey, RevCycleIntelligence, Private Equity Ownership of Rural Hospitals is Growing, Report Finds, 2023

25% of rural hospitals in each state are at risk of closure: Center for Healthcare Quality and Payment Reform, Rural Hospitals At Risk of Closure, 2023

Rural Americans are more likely to be uninsured: Medicaid and CHIP Payment and Access Commission, Medicaid and Rural Health, 2021

1 in 6 rural adults is uninsured: Gina Turrini et al., Assistant Secretary for Planning and Education, Department of Health & Human Services, Research Report: Access to Affordable Care in Rural America, Current Trends and Key Challenges, 2021

Medicaid plays a central role: Julia Foutz et al., Kaiser Family Foundation, The Role of Medicaid in Rural America, 2017

Distance and transportation -

• Longer distances to access care: Rural Health Information Hub, Healthcare Access in Rural Communities, 2022

• Specialty services are less likely to be available: Rural Health Information Hub, Rural Health Disparities, 2022

Health literacy: Rural Health Information Hub, Social Determinants of Health for Rural People, 2022

Affordability: Munira Z. Gunja, The Commonwealth Fund, Rural Americans Struggle with Medical Bills and Health Care Affordability, 2023

Higher poverty rates in rural areas: Economic Research Services, United States Department of Agriculture, Poverty rates by select racial and ethnic groups, residence, 2019.

• Note: This is the most current estimation of poverty rate comparisons. Data is from the US Department of Commerce, Bureau of the Census, 2019 American Community Survey.

Poverty and health outcomes: Office of Disease Prevention and Health Promotion, Healthy People 2020, Poverty, 2020

• Note: Poverty is linked to increased risk of mental illness, chronic disease, higher mortality, and lower life expectancy. Additional sources can be found in the Healthy People 2020 report.

Workforce shortages -

• Ratio of patients to primary care physicians: National Rural Health Association, About Rural Health Care, 2023

  • Original report: Esther Hing & Chun-Ju Hsiao, National Center for Health Statistics, Centers for Disease Control and Prevention, State Variability in Supply of Office-based Primary Care Providers: United States, 2012, 2014

• Workforce shortage areas: Bureau of Health Workforce, Health Resources and Service Administration, US Department of Health and Human Services, Designated Health Professional Shortage Areas Statistics, 2023

Only 10% of physicians practice in rural areas: American Hospital Association, Rural Hospital Closures Threaten Access: Solutions to Preserve Care in Local Communities, 2022

Improving and Addressing Access to Care in Rural America

Supporting and training rural providers: Elizabeth Burrows et al., National Rural Health Association, Health Care Workforce Distribution and Shortage Issues in Rural America, 2012

Improving access to specialized care: School of Public Health and Tropical Medicine, Tulane University, How to Improve Health Care in Rural Areas, 2023

Health care workforce distribution and shortage issues: Elizabeth Burrows et al., National Rural Health Association, Health Care Workforce Distribution and Shortage Issues in Rural America, 2012

Expanding non-physician provider abilities: Elizabeth Burrows et al., National Rural Health Association, Health Care Workforce Distribution and Shortage Issues in Rural America, 2012

Strengthening the rural provider safety net -

• Rural emergency hospitals: Michael Topchik et al., The Chartis Group, LLC, Rural Health Safety Net Under Renewed Pressure as Pandemic Fades, 2023

• School-based clinics: Angela Fairbanks, Boise State University, A helping hand in rural Idaho: Boise State and community partners open a school-based clinic, 2021

• Critical access hospitals: Rural Health Information Hub, Critical Access Hospitals, 2021

Telehealth in rural communities -

• Telehealth plays a crucial role in addressing the challenges of rural health care:

  • Centers for Disease Control and Prevention, Telehealth in Rural Communities, 2022

  • Shreya Kolluri et al., Health Psychology Research, Telehealth in Response to the Rural Health Disparity, 2022

  • Mary Charlton et al., Oncology (Williston Park), Challenges of Rural Cancer Care in the United States, 2015

• Telemedicine encounters pre- vs. post- pandemic: Annie E. Larson, American Journal of Preventive Medicine, Before and During Pandemic Telemedicine Use: An Analysis of Rural and Urban Safety-Net Clinics, 2022

  • Note: By using patient addresses linked to zip code approximations of rurality, the study was able to assign individuals as urban, large rural, small rural, or isolated rural. The categorizations were based on Rural-Urban Commuting Area (RUCA) codes, which are census tract-based classifications.

• Limited access to digital technology: Michael Miller, University of Cincinnati, Narrowing the digital divide for health care, 2023

• Rural population that lacks broadband access: Federal Communications Commissions, Fourteenth Broadband Deployment Report, 2021

  • Note: This is the most current released Broadband Deployment Report.

Additional barriers to telehealth -

• Licensing and Credentialing of Providers: Rural Health Information Hub, Licensing and Credentialing of Telehealth Programs, 2023

• Age & Education: Wendy Brunner et al., Telemedicine Journal and E-Health, Determinants of Telehealth Technologies in a Rural Population, 2023

• Comfortability with Technology and Virtual Care: Kathleen Y Li et al., Journal of Telemedicine and Telecare, Perceptions of telehealth among older U.S. adults during the COVID-19 pandemic: A national survey, 2023

Bridging the digital divide -

• $40 billion in funding: The White House, Fact Sheet: Biden-⁠Harris Administration Announces Over $40 Billion to Connect Everyone in America to Affordable, Reliable, High-Speed Internet, 2023

High-speed internet improves access to telehealth: Jacob Fischler, Washington State Standard, ‘The internet is no longer a luxury’: $667M from USDA for rural broadband, 2023