Reflecting across our more than 20-year collaboration of studying rural health issues, we can’t help but observe that interest in the health and well-being of rural U.S. residents appears to be at an all-time high. It’s not that the problems are new; data on the relatively poorer health of rural people have been available and of concern throughout our careers and in the many decades prior. Still, we understand why much of these data have received limited attention over the years. Studies of rural health escape general attention in much the same way that rural places themselves tend to exist beyond the public view—down dirt roads, amid croplands, in desert borderlands, or under a very big sky.
Yet, over the past year we have found ourselves increasingly called upon to speak to national audiences about rural places and to discuss the role of rural culture in health. Whether driven by rural contributions to the current opioid crisis, new data on the growing gap between rural and urban life expectancy, or even the 2016 election, we welcome this attention and hope it translates into sustained interest and investment in the health of rural people.
Growing evidence indicates that a significant rural-urban disparity in life expectancy exists in the United States, driven largely by urban longevity gains that have not been shared among those living in rural places. A recent study of the five leading causes of death in the United States (heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke) found that the age-adjusted death rate for each was higher among rural residents. Perhaps more disturbingly, the rate of potentially excess deaths in rural communities was also consistently higher. The federal Centers for Disease Control and Prevention consider excess deaths to include those that “might . . . be prevented through improved public health programs that support healthier behaviors and neighborhoods or better access to health care services.”
Part of the challenge for understanding and improving the health of rural populations lies in disentangling the underlying causes of their ill-health and death, which is further complicated by the socioeconomic and geographic heterogeneity of rural places and populations. Exacerbating efforts to tease out these differences, rural health experts have noted increasingly poor access to data on rural health, as financial issues and concerns for privacy have limited the availability of geographic indicators in many federal health surveys. Still, across the country, we have observed that many rural communities actually do embody the small town Rockwellian image that is often equated with life outside the city—places with county fairs, church dinners, strong bonds between neighbors, and children thriving under the collective community eye. However, many others suffer economic and environmental hazards and adverse health outcomes—like infant and maternal mortality—that rival lesser developed nations.
While there is substantial variation across the country, rural residents are more likely on average to live in poverty and to lack formal education; these interrelated social determinants are known contributors to sickness through a complicated pathway of poor health care access, health behaviors, and exposure to toxic levels of stress. In recent years, the rising mortality rate for rural working-class whites has been driven by what some researchers have begun calling “despair deaths.” These deaths represent those from suicide, liver disease, and accidental poisonings (including opioid and
These poorer economic circumstances of many rural populations and places relate to a host of downstream sequelae that have important implications for rural health. For example, while the Flint, Michigan, water crisis has sparked understandable outrage among public health and social justice advocates, rural places face their own challenges with potable drinking water. Runoff from rural industries, including mining and agriculture, has resulted in contaminants leeching into rural public and private water supplies across the country. Many rural households obtain their water from private wells, which may be affected by a range of different contaminants. In 2011, the Environmental Protection Agency reported that more than 2,000 rural communities were in serious violation of the Safe Water Drinking Act and estimates suggest that more 6 million rural residents have some problem with water contamination. On the housing side, a report by the U.S. Census Bureau indicates that rural residents are more likely than urban residents to have problems with the physical integrity of their homes, including serious structural issues like leaking or sagging roofs.
These underlying socioeconomic and environmental conditions are exacerbated by poorer health care access among rural residents and a more anemic rural health services infrastructure. Prior to passage of the Affordable Care Act (ACA), data across nearly four decades demonstrated that rural residents are more likely than urban residents to be uninsured. This has been particularly true in the southern and western United States, where as many as 25 percent of those under age 65 lacked health insurance in 2011. Even when rural residents have private health insurance, the coverage tends to be poorer and creates conditions under which rural residents are more likely to face high out-of-pocket costs for care. While the ACA held promise for reducing these disparities in coverage, the Supreme Court decision that made Medicaid expansion optional has resulted in uneven impact across the country. States with substantial rural population have been less likely to expand Medicaid under the ACA so that, overall, rural places have not experienced the same decline in uninsured rates as urban places.
Compounding these financial barriers to care, rural residents face access problems because many of their communities lack a sufficient number of health care professionals. Compared to large urban counties, remote rural places have less than half the per capita rate of primary care providers; that is, providers who provide day-to-day checkups, screenings, and chronic disease management. Because of the lower availability of health care providers within rural communities, many rural residents must travel great distances to seek health care. Given these travel requirements, reliable transportation is critical for ensuring rural health care access; however, many rural residents (particularly those at lower incomes) face transportation challenges including poor road conditions, unreliable vehicles, or difficulty affording gasoline.
This rural-urban difference in availability of health care professionals is particularly pronounced for specialty care providers. Compared to rural counties, urban counties have nearly nine times the per capita number of specialists. Specialty care providers include mental health professionals, which tend to be severely lacking in rural places. Around 60 percent of rural residents live in a designated mental health professional shortage area, meaning that there are insufficient providers (maybe even zero providers) available to address the mental health needs of that community. More than half of rural counties have no health care professional licensed to provide medication-assisted treatment for opioid dependence.