Despite the many positive attributes and assets associated with working and living in rural communities, many
rural American population groups experience 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, higher mortality rates, lower life expectancies, and higher rates of
chronic pain. 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. Rural residents are also less likely to have employer-provided health insurance
coverage, and if they are poor, often are not covered by Medicaid.
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 levels, while others work
with policymakers to help them understand the issues affecting population health and healthcare in rural
“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 greater
obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental
health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location;
or other characteristics historically linked to discrimination or exclusion.”
“The 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.”
“a health disparity that is not only unfair but may also reflect injustice. To address health
inequities, communities must remove obstacles to good health such as poverty, discrimination, and their
consequences, including: powerlessness and lack of access to well-paying jobs, quality education and housing,
safe environments, and health care (Braveman et al., 2017).”
What are the causes of rural health disparities?
The origins of health disparities in rural America are numerous and vary by region. Some frequently cited
factors underlying rural health disparities include access to healthcare and public health services,
socioeconomic status, health-related behaviors, and chronic conditions, as well as geographic distances,
infrastructure limitations, and provider shortages.
There are higher rates of uninsured individuals residing outside a metropolitan statistical area compared to
their counterparts within metropolitan statistical areas, as reported by the CDC's Health, United States, 2020-21, Table
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
workers with less education and training living in rural areas” and highlights data showing less than
all physicians and surgeons choose to practice in rural settings. In addition to this maldistribution,
nationwide shortages also exist. According to a 2020 report
from the Association of American Medical Colleges (AAMC), the U.S. may see a shortage of between 21,400 and
55,200 primary care physicians by 2033.
Specialty and subspecialty healthcare services are less likely to be available in rural areas and are less
likely to include highly sophisticated or high-intensity care. This exacerbates problems for rural patients
seeking specialized care who are faced with traveling significant distances for treatment. A 2019 policy
brief from the University of Minnesota Rural Health Research Center found that 64% of surveyed Rural
Health Clinic staff members reported difficulties finding specialists for patient referral.
Notably, reliable transportation can also be a barrier for rural residents accessing healthcare and public
health services 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
of limited transportation options on health in rural communities, see our Transportation to Support Rural Healthcare topic guide.
According to the 2021 Medicaid and CHIP Payment and Access Commission brief Medicaid and Rural
Health, rural residents have lower incomes than urban counterparts, and rural areas have overall higher
poverty rates, especially among rural racial and ethnic minority populations. The United Health Foundation's Health
Disparities Report 2021 includes rural and urban comparative data on social and economic factors
impacting health disparities. The report finds that between 2015-2019, rural populations had higher rates of
poverty and premature death than their urban counterparts.
The Neighborhood Atlas from the University
of Wisconsin School of Medicine and Public Health offers Area Deprivation Index (ADI) data at the census block
level. CDC's Social Vulnerability
Index (SVI) offers county-level comparisons of socioeconomic data, household composition, housing and
transportation data, and more.
Socioeconomic status and related challenges can fall under social determinants of health (SDOH). Healthy People 2030
defines social determinants of health as “the conditions in the environments where people are born, live,
learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes and risks.” Social determinants of health can include income and poverty, housing conditions,
educational attainment, race/ethnicity, access to healthcare, health literacy, environmental health, and other
factors that impact the attainment of health and wellness. For additional information about the causes of health
disparities in rural areas, see our Social Determinants of
Health for Rural People topic guide.
Health Insurance Status
The 2022 report Geographic Variation in Health
Insurance Coverage: United States, 2020 found that 58.5% of rural adults and 43.5% of rural children
held private insurance coverage in 2020, while 26.3% of rural adults and 52.0% of rural children held public
coverage and 17.9% of rural adults and 7.7% of rural children were uninsured. Compared to medium, small, large
fringe, and large central metropolitan populations, rural individuals had the lowest rate of private insurance
coverage, the highest rates of public coverage, and the highest uninsured status.
For more health insurance data, the State Health Access Data Assistance
Center (SHADAC) offers a state-by-state tool that presents data on health insurance coverage, access to
care, affordability, and healthcare utilization. The U.S. Census Bureau's Small Area Health Insurance Estimates
(SAHIE) Program offers a visualization of health
insurance coverage from 2008-2020 that depicts the proportion of persons uninsured under age 65 by
A 2019 American Journal of Public
Health study found that from 2008-2010 and 2014-2016, rates of cigarette smoking among rural
and urban adolescents declined, but that rural rates fell more slowly than urban rates. In 2014-2016, rural
youth had 50% higher odds of smoking cigarettes than urban adolescents.
According to a 2021 National Center for Health Statistics (NCHS) data brief, Trends in Death Rates in Urban and Rural Areas:
United States, 1999–2019, the age-adjusted death rate in rural areas was 7% higher than that of urban
areas, and by 2019 rural areas had a 20% higher death rate than urban areas. The brief found that the largest
urban-rural differences in deaths were from heart disease, cancer, and chronic lower respiratory disease.
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 from the NCHS brief compares several cause-specific mortality
rates for rural and urban counties.
Another way to examine rural-urban mortality differences is by examining potentially excess deaths, which are
those deaths that might have been preventable. A 2019 CDC MMWR, Potentially Excess Deaths from the Five Leading
Causes of Death in Metropolitan and Nonmetropolitan Counties — United States, 2010–2017, 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. The article defines excess deaths as deaths among people under 80 years of age that exceed the expected
number of deaths. Across counties in the U.S., the proportion of deaths that occur before age 80 varies; the
three states with the lowest rates are used as a benchmark for comparison.
Potentially Excess Deaths from the Five Leading Causes of Death in Metropolitan and Nonmetropolitan
Counties — United States, 2010–2017
4 of the 5 leading causes of death in rural areas are associated with chronic disease. Our 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 rural areas.
How does rural health status compare to urban?
In general, rural populations experience worse health status than urban populations. This is in part due to a
higher incidence of chronic conditions and higher engagement in health risk behaviors. According to the 2018
research brief Rural
Communities: Age, Income, and Health Status, rural populations of all age groups utilize preventative
health services at lower rates and are less likely than urban counterparts to have private health insurance.
Rural populations also have higher rates of disability, according to a 2019 American Journal of
Preventive Medicine article that found rural adults were 9% more likely to report a disability,
24% more likely to report 3 or more disabilities. The
and Health Promotion website offers more information on this study and its implications.
status data from the National Health Interview Survey, 2018 shows that 11.2% of respondents who live
outside a metropolitan statistical area (MSA) reported their health status as “fair” or “poor”
compared to 9.6% of respondents in small MSAs and 8.4% of respondents from large MSAs. Moreover, 39.3% of large
MSA respondents claimed “excellent” health compared to 34.7% of small MSA respondents and 31.2% of
respondents not residing in an MSA. For more data from the National Health Interview Survey, see the CDC's Summary Health Statistics Tables.
While rural health status is generally poorer than in more populated areas, health status disparities can vary
based on socioeconomic factors, access to outdoor spaces for physical activity, and state-level wellness and
disease prevention efforts. For state-level data, see the Kaiser Family Foundation's State Health Facts, which offer data on demographics, health
status, healthcare access, including state profiles and comparisons across the 50 states.
Rural community-based and other rural-serving organizations are working to address these issues through
investments in rural community assets, economic development, food security and nutrition, and public health
efforts. For more information on this work, see our Community Vitality and Rural
Healthcare topic guide.
How does rural life expectancy compare to urban?
Related to excess deaths, life expectancy is generally lower in rural than in urban counties.
Remaining Life Expectancy (LE) at Age 25, by Sex and Urbanization
The 2021 report Rural
Communities at Risk: Widening Health Disparities Present New Challenges in Aftermath of Pandemic
examines gaps in rural and urban access to primary care and mental health services, identifying significant
vulnerabilities in rural communities to health emergencies like the COVID-19 pandemic that increase the risk for
rural health disparities. The report also notes the risk of healthcare facility closures in rural areas, which
is an additional source of vulnerability for those communities. Additionally, a 2021 Journal of Rural Health
notes that inequities in healthcare access that existed before the pandemic were made more severe during the
pandemic, including aging rural hospital infrastructure, less access to ICU beds and ventilators, and less
access to specialty care.
What regions of the country experience higher levels of rural health disparities?
Higher levels of rural health disparities can be found in several regions throughout the U.S., although not all
of these regions exhibit similarly high levels in all identified disparities.
There are many areas of overlap between Appalachia and the South, and 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 2023 NORC Walsh Center for rural Health Analysis and East Tennessee State
University Center for Rural Health Research report, Appalachian
Diseases of Despair, found that in 2021 Appalachia had a higher all-cause mortality rate than other
parts of the U.S. While the all-cause mortality rate has seen a significant increase in the U.S. due to
COVID-19, the rate remains higher in Appalachia with 507.4 deaths per 100,000 when compared with the
non-Appalachia rate of 372.8 deaths per 100,000. 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. The 2021 report Creating a Culture of
Health in Appalachia: Disparities and Bright Spots also provides data on mortality from these
conditions, as well as years of potential life lost in the region. Other diseases and health concerns resulting
in elevated death rates throughout the region include septicemia, chronic liver disease, suicide, and overdoses
from prescription and illegal drugs. The American 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 Center for Health Services Research. See Resources by Topic: Appalachia for additional information and Rural Project Examples: Appalachia for examples of programs
working to decrease disparities.
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 all age groups 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 United States. However, persistent health issues
continue to afflict the border region. The 2021
Rural Border Health Chartbook offers data on health indicators, disparities, and social determinants of
health in rural border and non-border counties in Texas, New Mexico, Arizona, and California, covering access to
care, preventive services, health behaviors, COVID-19 impacts, and mortality. 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, particularly 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%. Our
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.
See Rural Project Examples: U.S.-Mexico Border
Region for examples of programs working to decrease disparities in the area.
Most of the 574 federally recognized American Indian tribal reservations and Alaska Native villages are in rural
areas. According to the U.S. Department of Health and Human Services Office of Minority Health's American Indian/Alaska Native
profile, 78% of American Indian/Alaska Native (AI/AN) populations reside in urban, suburban, or rural
off-reservation areas as of the 2010 Census. A 2019 Indian Health Service (IHS) fact sheet, Indian
Health Disparities, notes that AI/AN populations experience significantly higher mortality rates from
several causes. The fact sheet reports AI/AN life expectancy as 5.5 years lower 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
compared 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 in
mortality for numerous causes. AI/AN mortality rates were: 520% greater related to alcohol; 450% greater due to
tuberculosis; 368% greater related to chronic liver disease and cirrhosis; 207% greater related to motor vehicle
crashes; and 177% greater due to diabetes mellitus. The 2022 review article The Indian Health
Service and American Indian/Alaska Native Health Outcomes outlines health outcomes and disparities for
AI/AN populations and offers an overview of the history of the Indian Health Service. For more information on
tribal health or programs to address health disparities in AI/AN communities, see our Rural Tribal Health topic guide and for examples of programs working
to decrease disparities in AI/AN communities, see Rural Project Examples: American Indian or
Offering 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 U.S.
County Profiles data and maps on major causes of death by county for all 50 states.
Additionally, the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation
offer the County Health Rankings project, which provides
annual data on county-level health disparities, as well as social and economic factors that influence health
outcomes. The Robert Wood Johnson Foundation also awards the Culture of Health
Prize to communities advancing health, equity, and opportunity, with several rural and tribal
communities frequently featured as awardees.
What are the health disparities that affect rural racial and ethnic minority groups?
Racial and ethnic minority populations in rural areas often experience health disparities in health status,
of chronic disease, life expectancy, and rates of unintentional injury. In places where race and ethnicity
overlay with rural geography, residents often experience dual disparities and face some of the worst outcomes in
the nation. A 2017 MMWR, Racial/Ethnic
Health Disparities Among Rural Adults — United States, 2012–2015, examines health disparities for adult
rural minority populations compared to other racial or ethnic groups. The MMWR findings include:
Adult AI/AN, non-Hispanic Black, and Hispanic adults living in rural areas self-reported higher rates of
fair or poor health compared to non-Hispanic White adults.
Rural non-Hispanic Black and AI/AN adults were more likely to report having multiple chronic health
conditions than non-Hispanic White adults.
Rural non-Hispanic Black adults were most at risk for obesity and severe obesity.
Rural AI/AN adults reported the most limitations in activities due to physical, mental, and emotional
Rural minority communities face a myriad of issues that can affect population 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 Americans, AI/ANs, Asian Americans, Hispanics and Latinos, and
Native Hawaiians and Pacific Islanders 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 health needs of diverse rural populations and provides information,
expertise, and grant opportunities to address the health inequities found in rural racial and ethnic
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.
The National Institute on Minority Health and Human Disparities
(NIMHD) within the National Institutes of Health supports research that examines and addresses health
disparities among minority populations, sexual and gender minorities, socioeconomically disadvantaged
populations, and underserved rural populations.
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. Individual
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 (AHRQ).
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.
Also published by AHRQ, the Chartbook on
Rural Healthcare offers a summary of trends across various rural healthcare measures and includes
figures of specific measures. A slide deck is also available for users to download for presentation.
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.
The Rural Health Research Gateway's Health Disparities and
Health Equity topic page lists publications and projects on the topic of rural health disparities
and health equity developed by FORHP-funded rural health research centers.
Border Health Chartbook, published by the Rural and Minority Health Research Center in 2021,
presents a variety of health indicators and social determinants of health that contribute to health
disparities in rural and urban areas of the U.S.-Mexico border region. The chartbook offers data for
residents in Arizona, California, New Mexico, and Texas by self-reported ethnicity, rural-urban designation,
and proximity to the border. The data collected in the chartbook may be useful for public health officials,
policymakers, and other organizations looking to address health disparities in the region.
The HRSA Office of Health Equity's 2020 report Health
Equity Report 2019-2020 covers trends in health equity and health disparities within the U.S. It
addresses disparities related to social determinants of health and 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 and promotes better healthcare services in rural America. FORHP focuses on matters affecting rural
hospitals and healthcare, coordinates activities within the department related 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, and health equity.
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?
Our 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.