Rural Americans are a population group that experiences significant health disparities. Health disparities are
differences in health status when compared to the population overall, often characterized by indicators such as
higher incidence of disease and/or disability, increased mortality rates, lower life expectancies, and higher
rates of pain and suffering. Rural risk factors for health disparities include geographic isolation, lower
socioeconomic status, higher rates of health risk behaviors, limited access to healthcare specialists and
subspecialists, and limited job opportunities. This inequality is intensified as rural residents are less likely
to have employer-provided health insurance coverage, and if they are poor, often are not covered by
Federal and state agencies, membership organizations, and foundations are working to reduce these disparities
and improve the health and overall well-being of rural Americans. Some organizations provide funding,
information, and technical assistance to be used at the state, regional, and local level, while others work with
policymakers to help them understand the issues affecting population health and healthcare in rural America.
“a particular type of health difference that is closely linked with social, economic, and/or environmental
disadvantage. Health disparities adversely affect groups of people who have systematically experienced
obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age;
health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic
location; or other characteristics historically linked to discrimination or exclusion.”
“Attainment of the highest level of health for all people. Achieving health equity requires valuing everyone
equally with focused and ongoing societal efforts to address avoidable inequalities, historical and
contemporary injustices, and the elimination of health and health care disparities.”
The origins of health disparities in rural America are numerous and vary by region. Some frequently cited
factors underlying rural health disparities include healthcare access, socioeconomic status, health-related
behaviors, and chronic conditions.
There are higher rates of uninsured individuals residing in rural or nonmetro counties compared to their
counterparts in urban or metro counties, as reported by a 2021 CDC report Health, United States, 2019 (Table 49).
Healthcare workforce shortages are prevalent throughout rural America. The 2014 National Center for Health
Workforce Analysis report, Distribution
of U.S. Health Care Providers Residing in Rural and Urban Areas, found a “greater representation
of workers with less education and training living in rural areas” and highlights data showing less
than 8% of all physicians and surgeons choose to practice in rural settings.
Specialty and subspecialty healthcare services are less likely to be available in rural areas and are less
likely to include specialized and highly sophisticated or high-intensity care. This exacerbates problems for
rural patients seeking specialized care who are faced with traveling significant distances for treatment.
Reliable transportation to care can also be a barrier for rural residents due to long distances, poor road
conditions, and the limited availability of public transportation options in rural areas. For more
information on rural transportation programs and the impact on health of not having transport available in
rural communities, see RHIhub's Transportation
to Support Rural Healthcare topic guide.
For additional information regarding healthcare access in rural areas and other barriers rural populations face
related to access to care, see RHIhub's Healthcare Access in Rural
Communities topic guide.
According to a 2014 Kaiser Commission on Medicaid and the Uninsured issue brief, The
Affordable Care Act and Insurance Coverage in Rural Areas, rural populations have higher rates of low to
moderate income, are less likely to have employer-sponsored health insurance coverage, and are more likely to be
a beneficiary of Medicaid or another form of public health insurance. The brief found that rural residents are
more likely to be unemployed, have less post-secondary education, and have lower median household incomes
compared to urban residents. For additional information about the causes of health disparities in rural areas,
see RHIhub's Social Determinants of Health for Rural People
Update of the Rural-Urban Chartbook, from RHRPRC, reports a striking difference in the rates of
adolescent smoking among urban and rural classifications, with youth in rural noncore counties (11%) being more
than twice as likely to smoke as their peers in large central metropolitan counties (5%).
How do rural mortality rates compare to urban?
According to a 2017 North Carolina Rural Health Research and Policy Analysis Center findings brief, Regional Difference in Rural and Urban Mortality
Trends, from 1999 through 2015, both rural and urban all-cause mortality rates decreased, but decreases
were greater in urban areas, which increased the disparity for all-cause age-adjusted mortality between rural
and urban regions of the U.S.
With all-cause mortality rates higher in rural areas, it is no surprise that mortality related to certain causes
are also higher in rural areas. The table below compares several cause-specific mortality rates for rural and
Age-Adjusted Death Rates for the Five Leading Causes of Death per 100,000 Population: United
Cause of Death
Chronic lower respiratory disease
Source: Leading Causes of Death in Nonmetropolitan and Metropolitan Areas
— United States, 1999–2014,
Supplemental Tables, Morbidity and Mortality
Weekly Report, 66(1), 1-8, January 2017
Another way to examine rural-urban mortality differences is by examining excess deaths, that is, deaths that
occur at a younger age than would be expected. Across counties in the U.S., the proportion of deaths that occur
before age 80 varies; the lowest rate is used as a benchmark for comparison. Excess deaths are those that may
have been potentially preventable. A 2017 CDC MMWR, Leading Causes of Death in
Nonmetropolitan and Metropolitan Areas — United States, 1999-2014, analyzed CDC National Vital
Statistics System data and determined the 5 leading causes of death in the U.S. continue to demonstrate higher
percentages of excess deaths for populations in nonmetropolitan areas than in metropolitan areas.
Percentage of Excess (or Potentially Preventable) Deaths for Leading Causes of Death
Four of the five leading causes of death in rural areas are associated with chronic disease. RHIhub’s Chronic
Disease in Rural America topic guide provides additional information and resources on the impact of
chronic disease in rural areas, and lists funding opportunities for programs to address chronic conditions in
How does rural life expectancy compare to urban?
Related to excess deaths, life expectancy is generally lower in rural than in urban counties.
There are many areas of overlap between Appalachia and the South. Appalachia exhibits many of the same health
disparities found in the South. A 2017 Health Affairs article, Widening Disparities in Infant
Mortality and Life Expectancy Between Appalachia and the Rest of the United States, 1990–2013,
identified infant mortality rates 16% higher in the Appalachian region compared to the U.S. as a whole from 2009
to 2013. The article reports that the deficit in life expectancy for residents of Appalachia widened by 2.4
years from 1990 to 1992. The 2020 NORC Walsh Center for Rural Health Analysis report, Appalachian
Diseases of Despair, found that Appalachia had a higher all-cause mortality rate in 2018 than other
parts of the U.S., with 372.3 deaths per 100,000 in Appalachia and 280.5 deaths per 100,000 in non-Appalachian
regions. A research product from RHRPRC, Exploring
Rural and Urban Mortality Differences in the Appalachian Region, reports mortality rates for cancer,
heart disease, diabetes, lower respiratory diseases, unintentional injury, and stroke are higher in Appalachia
compared to the U.S. as a whole. Other diseases and health concerns causing death prevalent throughout the
include septicemia, chronic liver disease, suicide, and overdoses from prescription and illegal drugs. The
Psychiatric Association's (APA) 2017 publication, Mental
Health Disparities: Appalachian People, reports the “region's suicide rate is 17% higher than the
national rate” and rural Appalachian residents are 21% more likely to die by suicide compared to their
counterparts residing in larger metro counties in the region. Additional information and data on Appalachian
health disparities can be found in the 2017 report Health Disparities in
Appalachia from the Appalachian Regional Commission and the Cecil G. Sheps Centers for Health Services
Research. See Resources by Topic: Appalachia
for additional information.
The Delta Region
The Delta Region is located in the South but is limited to the rural geographic areas along the Mississippi
River. The Delta Region exhibits many of the same health disparities as the rural South and Appalachia. IHME's
U.S. Health Map offers data describing life
expectancy at birth for both sexes in 2014 in the Delta Region,
which are some of the lowest in the country. For example, the life expectancy for males at birth in 2014 in
Coahoma County, Mississippi is 67.24 years compared to 76.71 years for males born anywhere in the U.S. in 2014.
expectancy for females at birth in 2014 in Madison Parish, Louisiana is 74.21 years compared to 81.45 years for
females born anywhere in the U.S. in 2014. The RHRPRC research product, Exploring
Rural and Urban Mortality Differences in the Delta Region, reports rural mortality rates from
heart disease for age groups 1 to 14 years, 15 to 24 years, 25 to 65 years, and older than 65 years of age are
higher in the Delta Region compared to the U.S. as a whole. See Resources by Topic: Delta Region for additional
According to the 2013 Journal of Cross-Cultural Gerontology article, Border Health in the Shadow of the Hispanic
Paradox: Issues in the Conceptualization of Health Disparities in Older Mexican Americans Living in the
Southwest, many counties along the U.S.-Mexico border are “at or above life expectancy” compared to
other industrialized counties in the Southwest U.S. but persistent health issues continue to afflict the border
region. The 2015 United States-México Border Health Commission report, Healthy
Border 2020: A Prevention & Health Promotion Initiative, discusses the prevailing public health
issues for U.S.-Mexico border populations and identifies persistent health conditions for this population as
obesity, heart disease, diabetes, unintentional injuries, and tuberculosis. The report highlights the health
concerns and conditions, specifically asthma, as a result of poor air quality from pollution, emissions, and
other environmental particulates. Border counties can have higher rates of diabetes in the U.S. According to
2012 diabetes data for both sexes from IHME's U.S.
Health Map, the prevalence of diabetes was 26.38% in Starr
County, Texas, which was significantly higher than the diabetes prevalence rate for the state of Texas, 16.34%,
and for the U.S. population as whole, 14.28%. RHIhub's Rural Border Health topic guide provides
additional information on strategies used to improve health and access to care in rural border communities and
other relevant resources.
Tribal communities include Native American populations living on reservations, which is also sometimes referred
to as Indian Country. A 2019 Indian Health Service (IHS) fact sheet, Indian
Health Disparities, notes that American Indian/Alaska Native (AI/AN) populations experience
significantly higher mortality rates from several causes. The fact sheet reports AI/AN life expectancy as 5.5
years less compared to the rest of the U.S. population. APA's 2017 publication, Mental
Health Disparities: American Indians and Alaska Natives, reports that AI/AN adults and children have the
“highest rates of lifetime major depressive episodes and highest self-reported depression rates than any other
ethnic or racial group.” The APA publication found suicide to be the second leading cause of death for
AI/ANs age 10 to 34 and the completed suicide rate for AI/AN females aged 15 to 19 was four times higher
to their White female counterparts. The 2015 IHS report, Trends in Indian Health: 2014 Edition,
compares 2007-2009 AI/AN death rates to 2008 death rates for all U.S. races and reports significant differences
to mortality for numerous causes. AI/AN mortality rates were: 520% greater related to alcohol; 450% greater due
Tuberculosis; 368% greater related to chronic liver disease and cirrhosis; 207% greater related to motor vehicle
crashes; and 177% greater due to diabetes mellitus. For more information on tribal health or programs to address
health disparities in AI/AN communities, see RHIhub's Rural Tribal Health topic guide.
For additional information on regional rural health disparities, the U.S. Health Map from IHME at the
University of Washington is an interactive map that provides county-level data for the U.S. on life expectancy,
mortality rates, mortality risks, and other health risk factors. Map data can be narrowed by sex and is
available from 1980 through 2014. Health trend data by county is available for major causes of death, including
several types of cancer, heart disease, stroke, chronic lung diseases, diabetes, unintentional injury, and
mental and substance use disorders. IHME also publishes US
County Profiles data and maps on major causes of death by county for all 50 states.
What are the health disparities that affect rural minority populations?
Rural minorities face a myriad of issues that can affect their health and wellness ranging from chronic poverty,
to a lack of stable medical care for migrant workers, to language barriers or educational attainment affecting
healthcare decision making and communication. According to the HHS Action Plan to Reduce
Racial and Ethnic Health Disparities, the two major factors contributing to disproportionate health
problems are inadequate access to care and the provision of substandard quality healthcare services. Several
federal government agencies within the U.S. Department of Health and Human Services work to eliminate the health
disparities experienced by minority populations:
The Office of Minority Health (OMH) works to improve the
health status of racial and ethnic minorities, eliminate health disparities, and achieve health equity in
the U.S. OMH offers Minority
Population Profiles for African American, AI/AN, Asian American, Hispanic and Latino, and
Native Hawaiian and Pacific Islander populations that include various pieces of information such as a
demographic overview, educational attainment, health conditions, health insurance coverage, economics,
language fluency, U.S. Census reports, and more.
The Federal Office of Rural Health Policy (FORHP) has a
longstanding concern with the diverse health needs of rural minority populations and provides information,
expertise, and grant opportunities to address the inequities found in rural minority health populations.
The CDC Office of Minority Health and Health
Equity (OMHHE) aims to eliminate health disparities for vulnerable populations as defined by
race/ethnicity, socioeconomic status, geography, gender, age, disability status, sexuality, gender, and
among other populations identified to be at-risk for health disparities.
Every state has a state office of minority health or health equity office charged with reducing health
disparities within their state, providing state-level health information and resources targeted toward minority
populations. To find your state office of minority health or health equity office, see OMH's map of state minority health
Where can I find supporting documents and statistics on rural health disparities?
Several publications identify and describe the rural health disparities that include urban comparisons.
2014 Update of the Rural-Urban Chartbook highlights health trends and disparities
across different levels of metro and nonmetropolitan counties. The chartbook includes population
characteristics, health-related behaviors and risk factors, mortality rates, and healthcare access and use.
data tables in the chartbook are available in an Excel file.
A National Healthcare Quality and
Disparities Report is published annually by the Agency for Healthcare Research and Quality. This
report provides a comprehensive national overview of disparities in healthcare among racial, ethnic,
socioeconomic groups, and other factors in the U.S. population and rural areas. The report also tracks the
success of activities to reduce disparities.
Disparities: A Rural-Urban Chartbook is a research project presenting data on health disparities
experienced by people living in rural America. Some disparities identified are poorer health status, higher
prevalence of obesity, lesser options for activity, and higher mortality rates.
Health, United States presents an annual overview of
national trends in health statistics. The report covers
health status and determinants, healthcare utilization, access, and expenditures. To view rural data in the
Data Finder, select “Metropolitan and
nonmetropolitan” under Population Subgroups.
Rural Healthy People 2020 outlines a strategic
plan to identify rural health priority areas. The resource also documents the successes, challenges, and
relevant information for planning.
The Rural Health Research Gateway's Health Disparities
and Health Equity topic lists of publications and projects on the topic of rural health
disparities and health equity developed by FORHP-funded rural health research centers.
Border Health Chartbook II analyzes rural and urban U.S.-Mexico border counties by comparing them to
counties in the four border states and to other rural and urban counties in the U.S. Offers county-level
rates and statistics for socio-demographic factors, healthcare access, health outcomes, and more.
Equity Report 2017 covers trends in health equity and health disparities within the U.S. It
addresses disparities patterns for three priority areas: mental health, opioid use, and childhood obesity.
It includes a chapter specifically on rural and urban health disparities.
What agencies and organizations are working to seek solutions to these disparities?
The Federal Office of Rural Health Policy (FORHP)
is part of the Health Resources and Services Administration (HRSA) under the U.S. Department of Health and
Human Services, that promotes better healthcare services in rural America. FORHP focuses on matters
affecting rural hospitals and healthcare, coordinates activities within the department relating to rural
healthcare, maintains a national information clearinghouse, and provides rural-specific grant programs to
address many of the disparities affecting rural health.
The National Rural Health Association (NRHA) promotes
leadership, ideas, information, communication, education, research, advocacy, and methods to improve rural
health and reduce health disparities. NRHA is composed of individual and organizational members who share a
common interest in rural health.
The Robert Wood Johnson Foundation (RWJF) supports research and programs
devoted to health and healthcare. RWJF engages policymakers, business leaders, and community groups to
establish a national agenda for improving population health, well-being, health equity; achieving better
health; and tracking progress.
Rural Health Research Centers are funded by the
Federal Office of Rural Health Policy to produce policy-relevant research and analysis on healthcare and
issues impacting healthcare in rural areas. Research findings are also used to inform a wide audience of
national, state, and local decision-makers concerned with rural health.
The National Cancer Institute Center to Reduce
Cancer Health Disparities (CRCHD) conducts research on cancer health disparities. CRCHD works to
support cancer programs and inform policy to improve cancer health disparities research activities.
Where can I find programs that illustrate best practices to meet the challenges of providing health services in
areas characterized by disparities?
RHIhub's Rural Health Models and Innovations features examples of programs and
interventions that have shown success in providing health services in rural areas experiencing health
disparities. Models and innovations can be searched by evidence level, topic, source, and state. A few examples
of successful programs include:
Hidalgo Medical Services – Family Support Program is a community-based
chronic disease intervention program that works to help individuals with diabetes or those who are at risk
for diabetes. The program utilizes community health workers (CHWs) to provide education and support to
diabetic and pre-diabetic patients.
Kentucky Homeplace is a CHW initiative focused on reducing health
disparities in rural Kentucky. The model emphasizes coordinating care and health coaching while providing
many healthcare services at no cost to the patient.
Health Extension Rural Offices (HEROs) is a program that created local
community offices and community agents to help community members identify their health and social needs and
help them connect with the University of New Mexico Health Sciences Center (UNMHSC) and related resources.
Annually, RWJF recognizes communities working to improve health, well-being and health equity with the Culture of Health Prize.
To explore past Culture of Health Prize winners and their stories, search by topic and community type, including
rural and tribal communities, in the Meet the Culture of Health
Prize Winners section towards the bottom of the page.