Cultivating tailored approaches to help enable rural health equity

Why the approach to rural health equity needs reexamination

Rural areas account for 86% of the landmass in the United States and support most of the country’s agricultural and natural resource production.¹ Rural industries, such as agriculture, industrials, and tourism, cannot function without a healthy workforce. Despite this economic significance, many rural communities are underserved and marginalized leading to health inequities for an estimated 46 million US residents residing in these regions.²

On average, people in rural communities experience a 2.4-year shorter life span than people in urban communities.³ On top of long-standing challenges such as provider shortages, many rural hospitals have also recently seen decreasing margins and concerns about ongoing viability.⁴ Efforts to address rural health disparities are likely to greatly increase the overall health and well-being of the broader United States.

To better understand the distinctive strengths and needs of rural communities, our report examines what it means to be rural. It also outlines the imperative for health equity, highlights the tensions experienced in rural communities, and explores how a deeper understanding of the nuances unique to rural communities should impact the health ecosystem’s approach to health equity.

What it means to be rural—and how it defines needs

An examination of rural health equity requires defining what it means to be rural. The US government has no standard definition of rural and defines the topic differently across agencies. The definition utilized throughout this piece is provided by the Federal Office of Rural Health Policy.⁵

• All non-metro counties
• All metro census tracts with Rural-Urban Commuting Area (RUCA) codes 4–10
• Large-area metro census tracts of at least 400 sq. miles in area with population density of 35 or less per sq. mile with RUCA codes 2–3

When we look beyond the technical definition of rural communities, there are often preconceived notions of what it means to be rural—some of these perceptions are supported by evidence, and others are drawn from our own experiences and biases. Despite many commonalities, there are multiple identities encapsulated in the term “rural.” The individuality of each rural community should be considered as efforts to advance health equity are implemented across the country.

Rural communities experience many health inequities, some of which are similar to those experienced by urban areas, while others are more unique to rural communities. Explore additional data-rich examples in our full report.

Shared needs

• Food—Food insecurity is prevalent in both rural (10.8%) and urban regions (12.2%) as compared to suburban areas that have a lower food insecurity rate (8.8%).⁶
• Sustaining well-being: Mental health—Both rural and urban communities report a similarly high level of diagnosed mental health conditions. As a notable disparity, rural areas are reporting a suicide rate that is 55% higher (19.7 per 100,000 population) than in large urban areas (12.7 per 100,000 population).⁷

Distinct needs

• Childcare—An analysis across eight states found that 55% of children in rural communities live in areas with low or no childcare availability as compared to urban areas where about 33% of children experience low or no availability.⁸
• Infrastructure: Public transportation—Access to public transportation is more likely to be listed as a community need in rural communities (43%) as opposed to urban communities (19%).⁹

Understanding the health equity imperative for rural communities

Deloitte defines health equity as the fair and just opportunity for everyone to fulfill their human potential in all aspects of health and well-being.¹⁰ Equity in health and health care is affected by the intersection of economic, social, and environmental factors—the non-medical drivers of health. These factors compounded with influences like power, racism, and bias in and out of the health care ecosystem need to be addressed to help improve the health and wellness of the nation.¹¹

Surmount the toughest rural health care challenges

With the health ecosystem rapidly shifting, we’re moving toward a future where the industry will likely look beyond traditional health care delivery to upstream drivers of health. When shaping this new future, players should understand the nuances of rural identity, recognizing that each community has unique attributes, strengths, and needs that cannot be addressed with a blanket approach.

When done with intentionality and in collaboration across stakeholders, a future can be created where health is more accessible and equitable for rural populations across the United States. In embracing the diversity and uniqueness of rural communities, we can advance rural health equity and a healthier future for all.

Endnotes

¹Health Resources & Services Administration (HRSA), “Defining rural population,” based on 2010 US Census Bureau data, accessed December 4, 2023.

²Elizabeth A. Dobis et al., “Rural America at a glance,” US Department of Agriculture (USDA), Economic Research Service, Bulletin No. 230, November 2021.

³Zachary Levinson, Jamie Godwin, and Scott Hulver, “Rural hospitals face renewed financial challenges, especially in states that have not expanded Medicaid,” Kaiser Family Foundation (KFF), February 23, 2023.

⁴Ibid.

⁵HRSA, “Defining rural population.”

⁶Alisha Coleman-Jensen et al., Household food security in the United States in 2021, ERR-309, USDA, Economic Research Service, September 2022.

⁷Dawn A. Morales, Crystal L. Barksdale, and Andrea C. Beckel-Mitchener, “A call to action to address rural mental health disparities,” Journal of Clinical and Translational Science 4, no. 5 (October 2020): pp. 463–67; John Gale et al., Behavioral health in rural America: Challenges and opportunities, Rural Policy Research Institute (RPRI), December 2019.

⁸Katherine Paschall, Tamara Halle, and Kelly Maxwell, Early care and education in rural communities, OPRE Report #2020-62 (Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, US Department of Health and Human Services, 2020).

⁹Coleman-Jensen et al., Household food security in the United States in 2021.

¹⁰Kulleni Gebreyes et al., “Activating health equity,” Deloitte Insights, April 12, 2021.

¹¹Kulleni Gebreyes et al., “Addressing the drivers of health,” Deloitte Insights, November 5, 2021.

¹²HRSA, “Defining rural population.”

¹³US Census Bureau, “Our rural communities,” 2010 census data, last revised August 31, 2022.

¹⁴American Farm Bureau Federation (FB), “Fast facts about agriculture & food,” retrieved from 2021 Food and Farm Facts (Washington, DC: American Farm Bureau Federation, 2021).

¹⁵US Census Bureau, “Our rural communities.”

¹⁶Ibid.

¹⁷American Hospital Association (AHA), “Rural hospital closures threaten access: Solutions to preserve care in local communities,” September 2022.