Opportunities for a Healthier Rural America: Perspectives from the Rural Health Research Centers

by Jessica Rosencrans

The rural health landscape is constantly changing, and no two rural communities are exactly alike. Communities across rural America face different challenges based on their geography, resources, populations, and healthcare needs. At the same time, these challenges can create opportunities to learn from one another, share innovative ideas, and identify new ways to strengthen rural healthcare.

To explore the potential that exists for improving rural health at the national, state, and local levels, we asked directors of several Rural Health Research Centers (RHRCs) to weigh in on the question:

"What opportunities do you see to improve healthcare access and health outcomes for rural communities in the United States?"

Mark Holmes, PhD, Director
North Carolina Rural Health Research Center

Rural health policy has often focused on helping rural communities overcome disadvantages relative to urban healthcare systems. In practice, policy is frequently built around the realities of large, urban ecosystems and then modified ex post for rural contexts. The larger opportunity is to reverse that logic and to design systems that begin with rural communities themselves: centering their geography, economics, workforce constraints, institutional roles, and community needs.

First, we should modernize the delivery system. The goal should be to preserve reliable access to needed care, while recognizing that the most effective configuration of services may differ across rural communities. Decision-makers should ask which services rural residents need locally, which can be delivered virtually, and which should be organized regionally. Hospitals serve as essential clinical and economic anchors in many rural communities, but they are one part of a broader system of care. Some communities may be better served by a broader mix of primary care, behavioral health, emergency medical services, home-based care, pharmacy, public health, and telehealth-supported specialty care. Public-private partnerships, community-based organizations, such as faith-based organizations, and other non-healthcare actors could play vital roles. Payment and policy should support flexible models tailored to local needs rather than assuming a single delivery model will work in every rural community.

Second, we need a sustainable rural workforce strategy. Recruitment matters, but it is not enough. Rural workforce policy should support the full pathway: exposing rural students to health careers early, training professionals in rural places, expanding rural clinical rotations and residency opportunities, supporting advanced practice providers and other essential professionals, and prioritizing retention. It should also reduce unnecessary administrative burden, because in low-capacity environments, every hour spent on paperwork is an hour not spent on patient care. Telehealth can help extend scarce expertise, but it should complement, not replace, the trusted local workforce that rural residents depend on.

Third, payment and investment should reflect the realities of low-volume care. Lower volumes in rural settings often lead to higher per-unit costs. Low volume is not necessarily evidence of inefficiency; it is often an unavoidable consequence of maintaining access across large geographies and small populations. Fixed costs are spread across fewer people, longer distances, and smaller programs. Windshield time is a significant cost in rural intervention and care delivery. Policy should recognize the value of maintaining essential capacity, supporting readiness, and investing in the infrastructure that allows rural systems to adapt, including broadband, transportation, care coordination, data systems, and the role that healthcare institutions play in local economic development.

Ultimately, the measure of success should not be whether rural healthcare looks like urban healthcare. It should be whether rural residents can obtain timely, high-quality care close to home when possible, connect to regional and virtual resources when needed, and rely on sustainable systems that improve health outcomes as community needs change.

Janessa Graves, PhD, MPH, Director
WWAMI Rural Health Research Center

The greatest opportunity I see in rural health comes from the momentum from the Rural Health Transformation Program (RHTP) and similar investments. It's an exciting time! As states have proposed and begun implementing their programs, rural communities are enthusiastic about what lies ahead. Rural residents have become increasingly aware of the disparities in healthcare access and health outcomes facing their communities, and I am now seeing folks become more empowered to propose ideas and genuinely believe that solutions are possible.

The opportunity, then, is to harness this energy to fuel our efforts to affect change. These efforts should involve authentic engagement to build solutions together, with community members as partners from the start. Rural people possess valuable knowledge about their communities that will be important as we move forward with RHTP and related initiatives. This knowledge, such as which barriers keep people from accessing care and which local champions and institutions people trust, will help programs better fit our rural communities, which I believe will lead to greater acceptability, sustainability, and, ultimately, lasting improvement in rural healthcare access and health outcomes.

When rural communities are asked about their health needs (e.g., through community health assessments), one concern I seem to hear repeatedly is mental health and substance use. I think there is an opportunity now to focus on improved access to behavioral health services, defined broadly: not only counselors and clinics, but also programs that foster social connection and belonging, such as community programming, youth sports and clubs, and senior center activities. Many states' RHTP plans focus on behavioral health, which is great. I hope to see solutions built for people of all ages, from children to older adults. We should build partnerships, seek input, and ask for advice from rural people across the age spectrum. Bringing as many perspectives to the table as possible will help us design interventions that address needs or leverage strengths we might not have anticipated.

Enthusiasm fades quickly when there is limited follow-through, and, as a rural person myself, I know rural communities can have long memories. If this moment passes without making authentic connections that matter, we risk losing the engagement that has been building. So, the opportunity before us is to capture the energy and excitement within our rural communities and to build programs and interventions together. There is willingness and energy right now, and they represent an incredible opportunity to drive real, lasting change that will outlast those RHTP dollars.

Carrie Henning-Smith, PhD, MPH, MSW, Co-Director
University of Minnesota Rural Health Research Center

To improve rural health, it's important to first recognize what's already working in rural communities. There are countless examples of rural places that are thriving, innovative, creative, and that build on the many strengths of their rural population and natural resources. Too often, we start by looking at where things aren't working – or we fail to listen to the wisdom and ideas in rural communities. Approaching rural health by engaging rural populations and by using an asset-based perspective is essential to any meaningful change.

One example of this can be found in supporting the needs of rural older adults. I think we're too quick to focus on aging rural populations as a "challenge," which devalues whole groups of people. Instead, I like to say that rural communities are leading the way when it comes to aging, and that there are important lessons to be learned from rural places for the whole country as we undergo demographic shifts.

Several years ago, at the University of Minnesota Rural Health Research Center, we conducted research to better understand where the "oldest old" (a demographic term referring to people age 85 and older) were most likely to live. We found that in 56 counties across the U.S., 5% or more of their population was 85+; 54 of those were non-core rural counties. That might not surprise people who already think of rural communities as older. However, we also found that, on average, those 54 "oldest old" rural counties fared better than all other U.S. counties on a variety of population health measures, including smoking, obesity, food access, air quality, housing quality, and social connection. When we interviewed leaders in those 54 counties, we found that older adults themselves often held important community leadership roles and that their perspectives were valued by their neighbors. Aging populations were not a "problem" – instead, older adults were an essential part of the vitality of those communities.

Improving rural health also requires focusing on upstream drivers of health. While we need sustained and meaningful investment in rural healthcare, including funding to ensure that facilities and service lines remain viable, to grow the rural healthcare workforce, and to improve access to health insurance for all rural residents, healthcare is only a small piece of what makes up overall health. Improving rural health also requires resources to support transportation, housing, education, child care, social infrastructure, and access to healthy food. While examples of innovation in each of those areas can be found in rural communities across the country, the fact remains that not all rural communities have access to the same level of resources. Addressing upstream drivers of health in rural communities requires multi-sectoral partnerships and investment at the local, state, and federal levels. Such investment should be flexible to meet the individual needs of rural communities and, importantly, should build on the strengths and ideas already in rural places.

Peiyin Hung, PhD, and Elizabeth Crouch, PhD, Co-Directors
University of South Carolina Rural Health Research Center

At the University of South Carolina (USC) Rural Health Research Center (RHRC), we see opportunities in moving beyond one-size-fits-all programs and isolated pilot projects, toward locally tailored, regionally integrated systems. Given the variations in geography, population, infrastructure, and service capacity across rural communities, policy interventions would benefit from localized scaling and sustained financing. Current funding initiatives from the Health Resources and Services Administration (HRSA) and Centers for Medicare & Medicaid Services (CMS) facilitate the alignment of evidence-based prevention, technology-enabled care, workforce development, and regional coordination.

First, expanding digital infrastructure and clinical networks presents a promising mechanism for improving care access in rural areas. Telehealth, interoperable health information exchange, remote patient monitoring, and validated artificial intelligence (AI) tools may connect rural community health centers, Federally Qualified Health Centers, health clinics, and hospitals with specialty expertise, while also extending chronic disease management to the patient's home. For example, rural provider-to-provider telehealth produced similar or better results than traditional in-person care for several clinical applications and clinician outcomes. In a randomized trial of low-income rural adults with poorly controlled diabetes, technology-assisted nurse case management improved glycemic control. AI-assisted screening in rural settings may also expand access, but successful adoption requires clinical oversight, staffing, training, and workflow integration. Limited health information exchange among small and rural providers also creates persistent gaps in broadband, IT staffing, and financial resources.

Second, evolving electronic health record (EHR) data and health services research provide promising opportunities for more granular rural analytics (race/ethnicity, disability, income, gender, age, and geography) to drive more precise policy and clinical actions. These data can also support assessment of transportation, food, housing, benefits, and other health-related social needs. Community health workers can connect clinical services with local knowledge and resources; available evidence indicates that these programs can improve selected measures of primary care use and chronic disease management among populations experiencing disparities.

Third, improving maternal and child health outcomes may benefit from systemic redesign. For example, networks that coordinate obstetric providers, pediatric/neonatal resources, and specialty consultation can preserve local access while establishing clear pathways to higher-acuity care. HRSA's Rural Maternity and Obstetrics Management Strategies program illustrates this network-based approach. In addition, improving postpartum outcomes requires care coordination and insurance continuity, particularly for Medicaid/Children's Health Insurance Program (CHIP) enrollees, where coverage gaps can disrupt follow-up. Additional opportunities include sustained postpartum coverage, structural discharge planning, reliable referral and transportation systems, and evidence-based home visiting when appropriate.

Equally critical is the rural workforce. States are moving beyond basic recruitment by investing in comprehensive pipelines, guiding students from middle school through graduate clinical training, while offering vital retention support through professional development, team-based practice, housing, and family integration. The Federal Office of Rural Health Policy's (FORHP) Rural Residency Planning and Development program reflects the importance of training physicians where they are needed. Mobile models, including community paramedicine, can complement fixed rural facilities by bringing screening, follow-up, and lower-acuity care closer to residents.

The central opportunity is integration: combining advanced digital technology, evolving mobile care units, supported workforce pipelines, specialized care integration, and sustainable financing, the U.S. can build a rural healthcare infrastructure that is accessible, effective, and built to last.

Opinions expressed are those of the interviewees and do not necessarily reflect the views of the Rural Health Information Hub or the Federal Office of Rural Health Policy.