Despite the perceived idyllic nature of rural communities, many Americans living in these areas face significant health challenges. These are known as health disparities – differences in health status compared to the overall population – often manifesting as higher disease rates, disabilities, mortality, lower life expectancy, and chronic pain. Factors contributing to these disparities in rural areas include geographic isolation, lower socioeconomic status, higher rates of risky health behaviors, and limited access to healthcare specialists and job opportunities. Furthermore, rural residents are less likely to have health insurance through their employers and may lack Medicaid coverage if they are low-income.
Organizations at the federal, state, and local levels are actively working to address these disparities and improve the health and well-being of rural Americans. These efforts range from providing funding and technical assistance to informing policymakers about the unique health challenges in rural America.
The Centers for Disease Control and Prevention (CDC) has extensively documented these issues. Their Morbidity and Mortality Weekly Report (MMWR) Rural Health Series from 2017-2018, along with ongoing reports, delves into rural mortality, preventable deaths, health-related behaviors, chronic diseases, and mental health service access in rural communities. Notably, a 2021 CDC report, Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019, highlights the widening gap in mortality rates between rural and urban areas across the top 10 causes of death.
Frequently Asked Questions About Rural Health Disparities
What Factors Drive Rural Health Disparities?
The roots of health disparities in rural America are complex and vary across regions. Key contributing factors include challenges in accessing healthcare and public health services, socioeconomic disadvantages, unhealthy behaviors, prevalent chronic conditions, vast geographic distances, infrastructure limitations, and shortages of healthcare providers.
Access to Healthcare and Public Health Services
Limited access to healthcare is a major driver of health disparities in rural areas. A 2019 study in JAMA Internal Medicine demonstrated a link between primary care physician availability and mortality, finding that increasing primary care physicians by 10 per 100,000 people was associated with lower mortality rates. Rural Americans face numerous obstacles in accessing healthcare:
- Transportation: Long distances to healthcare facilities, lack of public transportation, and transportation costs create significant barriers.
- Provider Shortages: Rural areas often struggle to attract and retain physicians, specialists, and other healthcare professionals.
- Hospital Closures: Rural hospital closures further reduce access to vital healthcare services.
- Limited Services: Rural areas may lack specialized services, requiring residents to travel long distances for specialized care.
- Insurance Coverage: Lower rates of employer-sponsored insurance and higher uninsured rates in some rural populations restrict access to care.
Caption: This graph illustrates the trends in age-adjusted death rates across urban and rural classifications in the United States from 1999 to 2019, highlighting the growing disparity over two decades.
For more detailed information, explore our topic guides on Healthcare Access in Rural Communities and Rural Public Health Agencies.
Socioeconomic Status
Rural communities often experience significant socioeconomic challenges that impact health. A 2021 report by the Medicaid and CHIP Payment and Access Commission indicated that rural residents generally have lower incomes and higher poverty rates than their urban counterparts, particularly among racial and ethnic minorities in rural areas. The United Health Foundation’s Health Disparities Report 2021 further emphasizes this, showing higher poverty and premature death rates in rural populations compared to urban populations between 2015 and 2019.
Resources like the University of Wisconsin School of Medicine and Public Health’s Neighborhood Atlas, which provides Area Deprivation Index (ADI) data, and the CDC’s Social Vulnerability Index (SVI) offer detailed socioeconomic data at the census block and county levels, respectively.
These socioeconomic factors are key social determinants of health (SDOH). Healthy People 2030 defines SDOH as environmental conditions affecting health outcomes and risks, including income, housing, education, race/ethnicity, healthcare access, health literacy, and environmental health. Learn more in our topic guide on Social Determinants of Health for Rural People.
Health Insurance Status
Lack of adequate health insurance is a significant barrier to healthcare access in rural areas. The 2022 report Geographic Variation in Health Insurance Coverage: United States, 2020 revealed that rural adults and children have lower rates of private health insurance compared to metropolitan areas. In 2020, a substantial percentage of rural adults (17.9%) were uninsured, and while rural children had higher rates of public coverage (52.0%), disparities in private coverage remained.
The State Health Access Data Assistance Center (SHADAC) and the U.S. Census Bureau’s Small Area Health Insurance Estimates (SAHIE) Program (health insurance coverage from 2008-2020) provide further data and visualizations on health insurance coverage at the state and county levels.
Health Behaviors
Community-level health behaviors significantly influence health disparities. A 2017 CDC MMWR study, Health-Related Behaviors by Urban-Rural County Classification — United States, 2013, found that urban residents were more likely to engage in multiple positive health behaviors (non-smoking, moderate drinking, normal body weight, physical activity, and sufficient sleep).
| Behavior | Large metro center | Large fringe metro | Medium metro | Small metro | Micropolitan | Noncore |
|---|---|---|---|---|---|---|
| Current nonsmoking | 83.9% | 82.3% | 80.5% | 77.5% | 76.5% | 74.9% |
| Non- or moderate drinking | 61.1% | 59.9% | 63.3% | 64.3% | 67.3% | 68.6% |
| Maintaining normal body weight | 36.5% | 35.3% | 33.3% | 32.9% | 30.6% | 28.9% |
| Meeting aerobic activity recommendations | 51.4% | 51.4% | 51.1% | 50.7% | 49.2% | 46.7% |
| Sufficient sleep | 62.4% | 61.7% | 62.4% | 62.1% | 61.1% | 61.5% |
| Reported 4 or 5 of these health-related behaviors | 31.7% | 30.2% | 30.5% | 29.5% | 28.8% | 27.0% |
A 2019 American Journal of Public Health study indicated that while adolescent smoking rates declined in both rural and urban areas between 2008-2010 and 2014-2016, the decline was slower in rural areas. Rural youth in 2014-2016 were 50% more likely to smoke cigarettes than urban adolescents.
The Agency for Healthcare Research and Quality’s 2019 National Healthcare Quality and Disparities Report: Chartbook on Rural Health Care provides further data on health behaviors and disparities in rural and urban populations.
Rural vs. Urban Mortality Rates
Mortality rates are significantly higher in rural areas compared to urban centers. A 2021 National Center for Health Statistics (NCHS) data brief, Trends in Death Rates in Urban and Rural Areas: United States, 1999–2019, revealed that by 2019, rural areas had a 20% higher death rate than urban areas, a significant increase from a 7% difference in 1999. The largest differences were observed in deaths from heart disease, cancer, and chronic lower respiratory disease.
Caption: This chart compares the age-adjusted death rates for the ten leading causes of death in the United States, broken down by urban and rural classifications for the year 2019, highlighting the disparities in mortality across different causes.
Further analysis of “potentially excess deaths” – deaths before age 80 that are considered preventable – underscores the disparity. A 2019 CDC MMWR study, Potentially Excess Deaths from the Five Leading Causes of Death in Metropolitan and Nonmetropolitan Counties — United States, 2010–2017, found higher percentages of excess deaths in nonmetropolitan areas for the five leading causes of death.
| Cause of Death | Noncore | Micropolitan | Small Metro | Medium Metro | Large Fringe Metro | Large Central Metro |
|---|---|---|---|---|---|---|
| Heart Disease | 44.9% | 41.8% | 34.8% | 30.1% | 18.5% | 28.0% |
| Cancer | 21.7% | 19.9% | 13.5% | 10.3% | 4.0% | 3.2% |
| Unintentional injury | 64.1% | 61.1% | 55.5% | 57.6% | 50.6% | 47.8% |
| Chronic lower respiratory disease | 57.1% | 54.6% | 47.2% | 39.8% | 23.4% | 13.0% |
| Stroke | 37.8% | 35.0% | 31.4% | 28.9% | 17.0% | 27.4% |
A 2020 study, Rural-Urban Residence and Mortality among Three Cohorts of U.S. Adults, found a 10% higher risk of death for rural residents between 1997 and 2011. The North Carolina Rural Health Research and Policy Analysis Center’s report, Regional Difference in Rural and Urban Mortality Trends, offers a regional analysis of mortality rates from 1999-2015.
Chronic diseases are major contributors to mortality in rural areas. Our topic guide on Chronic Disease in Rural America provides extensive information and resources.
Rural vs. Urban Health Status
Generally, rural populations experience poorer health status compared to urban populations. This is linked to higher rates of chronic conditions and risk behaviors. A 2018 research brief, Rural Communities: Age, Income, and Health Status, highlighted lower utilization of preventative health services and lower rates of private health insurance in rural areas across all age groups. A 2019 American Journal of Preventive Medicine study found rural adults were significantly more likely to report disabilities. The CDC’s Disability and Health Promotion website provides more details.
Data from the National Health Interview Survey (2018) indicates a higher percentage of rural residents self-reporting “fair” or “poor” health status compared to urban residents. Conversely, a smaller percentage of rural residents report “excellent” health.
While rural health status is generally worse, disparities can vary based on socioeconomic factors, access to outdoor recreation, and state-level health initiatives. The Kaiser Family Foundation’s State Health Facts offers state-level data on demographics, health status, and healthcare access.
Community-based organizations are working to improve rural health through investments in community assets, economic development, food security, and public health initiatives. See our topic guide on Community Vitality and Rural Healthcare for more information.
Rural vs. Urban Life Expectancy
Life expectancy is typically lower in rural counties than in urban counties, reflecting higher mortality rates.
| LE in 1999 | LE in 2010 | LE in 2019 |
|---|---|---|
| Rural Women | 55.11 | 55.78 |
| Urban Women | 55.64 | 57.52 |
| Rural Men | 49.76 | 51.13 |
| Urban Men | 50.76 | 53.07 |
The U.S. Small-area Life Expectancy Estimates Project (USALEEP), a collaboration between the Robert Wood Johnson Foundation (RWJF) and the National Association of Public Health Statistics and Information Systems (NAPHSIS), provides detailed life expectancy data. RWJF’s interactive tool, Life Expectancy: Could Where You Live Influence How Long You Live?, allows users to explore life expectancy by ZIP code and neighborhood.
COVID-19 and Rural Health Disparities
The COVID-19 pandemic highlighted pre-existing health vulnerabilities in rural areas. Higher rates of chronic conditions in rural populations increased the risk of severe COVID-19 illness and death. CDC data showed higher per capita COVID-19 death rates in rural counties. A 2020 MMWR article, Estimated County-Level Prevalence of Selected Underlying Medical Conditions Associated with Increased Risk for Severe COVID-19 Illness — United States, 2018, examined these underlying conditions and their prevalence.
The 2021 report, Rural Communities at Risk: Widening Health Disparities Present New Challenges in Aftermath of Pandemic, emphasized the pandemic’s exacerbation of rural health disparities, particularly regarding access to primary care, mental health services, and the risk of rural hospital closures. A 2021 Journal of Rural Health article further noted the strain on aging rural healthcare infrastructure and limited access to critical care resources during the pandemic.
Regions with Significant Rural Health Disparities
Certain regions of the U.S. experience particularly pronounced rural health disparities.
The South
The rural South exhibits high mortality rates across nearly all top ten causes of death. CDC data visualizations from the 2019 report on Potentially Excess Deaths indicate higher percentages of excess deaths in the Southeast. The Institute for Health Metrics and Evaluation (IHME) U.S. Health Map also shows lower life expectancy in the South. Explore our resources on The South and Rural Project Examples: The South.
Appalachia
Appalachia shares many health disparities with the South. A 2017 Health Affairs article highlighted significantly higher infant mortality rates and a widening life expectancy gap in Appalachia compared to the rest of the U.S. A 2024 report, Appalachian Diseases of Despair, reported higher all-cause mortality and mortality from overdose, suicide, and alcoholic liver disease in Appalachia. Research from the Rural Health Reform Policy Research Center (RHRPRC) and the 2021 report Creating a Culture of Health in Appalachia: Disparities and Bright Spots further detail higher mortality rates for various diseases in the region. The American Psychiatric Association (APA) also notes higher suicide rates in Appalachia. The Appalachian Regional Commission’s 2017 report, Health Disparities in Appalachia, provides comprehensive data. See resources for Appalachia and Rural Project Examples: Appalachia.
The Delta Region
The Delta Region, along the Mississippi River, faces similar health disparities. IHME’s U.S. Health Map shows some of the lowest life expectancies in the country in this region. RHRPRC research indicates higher rural mortality rates from heart disease in the Delta. See resources for the Delta Region.
U.S.-Mexico Border
While some areas along the U.S.-Mexico border exhibit surprisingly high life expectancy, persistent health challenges remain. The 2021 Rural Border Health Chartbook provides data on health disparities in the border region, and the 2015 United States-México Border Health Commission report, Healthy Border 2020, outlines ongoing public health issues, including environmental health concerns in colonias – rural communities lacking basic infrastructure. The EPA’s Border 2025 report addresses environmental health initiatives. Explore Rural Project Examples: U.S.-Mexico Border Region.
Tribal Communities
American Indian and Alaska Native (AI/AN) tribal communities, largely located in rural areas, experience significant health disparities. The Indian Health Service (IHS) reports lower life expectancy and higher mortality rates from various causes for AI/AN populations. The APA highlights higher rates of depression and suicide in AI/AN communities. The 2015 IHS report, Trends in Indian Health: 2014 Edition, and a 2022 review article in Annual Review of Public Health further detail these disparities. See our topic guide on Rural Tribal Health and Rural Project Examples: American Indian or Alaska Native.
The IHME U.S. Health Map and U.S. County Profiles offer interactive county-level health data. The University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation’s County Health Rankings project also provides annual county-level health disparity data. The Robert Wood Johnson Foundation’s Culture of Health Prize recognizes communities addressing health equity.
Resources for Rural Health Disparities Data
For more information on rural/urban health disparities, see What sources cover health behaviors and health status for rural areas or by county?.
Organizations Addressing Rural Health Disparities
For rural health research information, see Conducting Rural Health Research, Needs Assessments, and Program Evaluations.
Best Practices in Rural Health Service Delivery
Explore successful programs in our Rural Health Models and Innovations database. The Robert Wood Johnson Foundation’s Culture of Health Prize also highlights exemplary communities. Our listing of Other Case Studies and Collections of Program Examples provides additional resources.
Last Updated: 11/12/2024
Last Reviewed: 11/28/2022
