Rural Americans—who make up at least 15 to 20% of the U.S. population—face inequities that result in worse health care than that of urban and suburban residents.
These rural health disparities are deeply rooted in economic, social, racial, ethnic, geographic, and health workforce factors. That complex mix limits access to care, makes finding solutions more difficult, and intensifies problems for rural communities everywhere.
“When you don’t get your health care taken care of, you wind up with disease presentations that are much farther along. People with cancer show up with metastatic cancer, people with diabetes show up with end-organ damage,” said Joseph Florence, MD, professor of family medicine and director of rural programs at Eastern Tennessee State University Quillen College of Medicine.
Consider one patient who came to a rural clinic affiliated with Quillen. The man had a large abscess that needed draining to help treat the infection. Although rural patients are less likely to have health insurance, he was insured. Yet, like many in rural areas, he couldn’t find a plan provider within an hour or two of his home.
“We just happened to have a free clinic that night, so we took care of him there,” said Florence. “But that’s just a once-a-month event, to give medical students some experience, not a way to provide health care.”
Challenges to rural health
U.S. rural communities—from Appalachia and the Deep South to the Midwest and western states to Alaska and Hawaii—share common risks for poorer health. These challenges, including few local doctors, poverty, and remote locations, contribute to lack of access to care.
Compared with urban areas, rural populations have lower median household incomes, a higher percentage of children living in poverty, fewer adults with postsecondary educations, more uninsured residents under age 65, and higher rates of mortality, according to a 2017 report by the North Carolina Rural Health Research Program (NC RHRP) at The University of North Carolina at Chapel Hill.
Rural residents who live on farms, ranches, reservations, and frontiers often must travel long distances to reach a health care provider. That means taking hours off from work for an initial appointment or follow-up, which causes many to delay or avoid care.
Greater distances also result in longer wait times for rural emergency medical services (EMS). That can endanger patients requiring EMS treatment. “If you’re bleeding, in that extra 15 minutes (before help arrives), you can die,” said Gary Hart, PhD, director of the Center for Rural Health, University of North Dakota School of Medicine and Health Sciences, in Grand Forks.
“Access to providers, even family physicians, is a problem. If you want to go to an OB/GYN, depending on where you live in the country, you may have to go 200 miles.”
Gary Hart, PhD
University of North Dakota School of Medicine and Health Sciences
Physician shortages contribute to many rural health difficulties. Primary care doctors are stretched thin, and specialists, including mental health and substance abuse providers, are a rarity [see sidebar].
“Access to providers, even family physicians, is a problem,” Hart said. “If you want to go to an OB/GYN, depending on where you live in the country, you may have to go 200 miles.” In a study published in September 2017 by researchers from the University of Minnesota School of Public Health, as of 2014, 54% of rural counties did not have a hospital with obstetrics services.
According to the U.S. Department of Veterans Affairs (VA), 25% of U.S. veterans live in rural areas. Compared with 36% of urban military veterans, more than half of rural-dwelling veterans are enrolled in the VA health system, yet many live far from the nearest VA medical center.
Some medical schools are deliberately preparing students to meet the needs of rural populations. Quillen was founded to meet regional needs and looks for students who might be likely to “go back into a rural area and do primary care,” Florence said. Students receive rural exposure during training, including through rural immersion experiences and learning from faculty with backgrounds in rural care. They conduct physicals for children in rural elementary schools and Head Start programs, gaining insight into differences with urban children.
Quillen’s curriculum builds students’ cultural sensitivity to rural patients. For example, said Florence, when a rural patient has gastrointestinal pain, the doctor needs to ask, “Do you have well water? Is it a drilled well or a dug well (which is at greater risk of contamination)? Are you working in the fields, out where it’s hot?”
“You have this textbook of medicine that you have to cover,” he said, but the school presents that knowledge to reflect “taking care of patients in the context of where they’re coming from, where they’re living.”
The diversity of rural America
While rural communities share common challenges, their residents may be racially and ethnically varied, with distinct health inequities. “We look at differences through rural-urban classifications, but when you layer in the issues of race and ethnicity, you find even greater disparities [within rural populations],” said Alana Knudson, PhD, codirector of the NORC Walsh Center for Rural Health Analysis at the University of Chicago.
African Americans are the largest rural minority. In the Deep South, once centered on the use of slaves in agriculture, some rural counties have large or majority African American populations. “There’s not a lot of migration out of state. It takes a lot to leave a place you’ve grown up in,” said Monica L. Baskin, PhD, a professor in the Division of Preventive Medicine at The University of Alabama at Birmingham (UAB) School of Medicine.
Rural African Americans have higher rates of cancer morbidity and mortality than other rural residents and have higher rates of comorbid conditions. “These are the same disparities you see nationally, with African Americans tending to have higher rates of these conditions,” Baskin said. “But in the rural communities we work with [in Mississippi and Alabama], there’s an even greater likelihood for them.”
“We look at differences through rural-urban classifications, but when you layer in the issues of race and ethnicity, you find even greater disparities [within rural populations].”
Alana Knudson, PhD
NORC Walsh Center for Rural Health Analysis, University of Chicago
The most recent U.S. census, which measured population changes from 2000 to 2010, showed that rural diversity has been increasing. Non-Hispanic whites were about 80% of rural dwellers in 2010 but accounted for only 25% of rural population growth. Over that same decade, rural Hispanics increased about 45% to 3.8 million people, almost equal to rural African Americans. Native Americans increased by 8%. The number of Asians rose by about 37%, although remaining a small part of the total rural population.
In his Central Appalachian area, Florence said, the Hispanic community has grown considerably in the past 15 years, with a smaller Haitian population arriving more recently. Some are migrant workers, for whom health care is “pretty sporadic,” he said. “When I see a migrant tomato farmer, he might have been without his blood pressure medicine for six months. Yet he continues to work every day.”
The NC RHRP reports that at least 80 rural hospitals in 26 states have closed since January 2010. Many are in communities with significant black or Hispanic populations. One such Alabama hospital closed in September and was located in a county where 72% of residents are African American. The nearest hospitals are now about 50 minutes away.
To increase access to specialists, UAB connects patients with physicians through its telehealth program. Using technology eliminates what can be, for some patients, a four-hour drive to Birmingham, said Baskin. Some areas without internet or broadband coverage are reached through conference calls and DVDs.
Higher disease incidence, worse outcomes
The rural-urban health care divide manifests clearly in breakdowns of conditions and outcomes. According to the Centers for Disease Control and Prevention (CDC), rates for the five leading causes of death in the United States—heart disease, cancer, unintentional injury (including vehicle accidents and opioid overdoses), chronic lower respiratory disease, and stroke—are higher in rural communities.
While overall mortality rates have been declining nationwide, rural areas have had a much slower decrease. They have higher infant mortality and greater rates of mental, behavioral, and developmental disorders in children. Rural youth and rural veterans have higher rates of suicide than their urban peers.
Rural residents are also more likely to have cancers related to modifiable risks, such as tobacco use, human papillomavirus (HPV), and lack of preventive colorectal and cervical cancer screenings.
UAB has a rural cancer prevention program that trains local residents and nonprofit organizations to deliver health promotion activities and evidence-based programs. “We make sure the interventions we’re doing are scalable and sustainable,” Baskin said.
Although smoking has greatly decreased in much of the United States, “adults in rural counties are still smoking at the same rate, or somewhat higher, than they were 10 years ago,” said Knudson. Twice as many rural youth smoke as do their urban peers, so she expects the higher rural rates of tobacco-related diseases and mortality to continue.
The CDC also cites opioid overdose deaths as 45% higher in rural areas, yet urban patients have easier access to treatment facilities. In Central Appalachia, “we’re just devastated by it,” said Florence. From 2008 to 2014, rural communities saw an increase of infants born with neonatal abstinence syndrome—a condition related to maternal opioid use—that was about two and one-half times higher than in urban areas.
The factors involved in rural health disparities are “not just something that our physicians can deal with,” Knudson said. “We need to figure out how to use these data to target resources and interventions to make a meaningful difference in improving the health of rural America.”