America's worst places to get sick: A call for White House action

The vice-presidential debate airs next Tuesday, October 3, and both VP-hopefuls are expected to highlight rural issues important to voters, given their shared roots in rural America. The republican nominee, Ohio Senator JD Vance, has described his Appalachian roots in his book Hillbilly Elegy, and democratic nominee, Minnesota Governor Tim Walz, who grew up in a small town in Nebraska, has projected a rural image as he’s traveled the country to speak with voters.

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A blog post from Health Providers Choice discussing what travel nurses can expect regarding healthcare when moving between urban and rural areas provides some clues on the distinctions.^[]

Urban hospitals have higher patient volumes, and the populations they serve tend to be more diverse. On the other hand, rural centers have lower patient volumes but may have a harder time filling positions, resulting in more extensive staffing shortages. 

The Centers for Medicare & Medicaid Services has examined whether Medicare beneficiaries living in different parts of the country are getting disparate care. In its latest report on the subject, from 2023, they noted, “Prior studies have found higher rates of chronic illness and poorer overall health in rural communities than in urban populations. One possible source of these differences in morbidity is disparate experiences with health care and differences in access to high-quality care between rural and urban areas.”^[]

Although patient experience around things like the ability to make appointments and to get necessary care quickly was generally similar regardless of location, clinical care was more likely to differ between urban and rural areas. On 39 clinical quality measures, urban residents received care similar to the national average for all but one, which was above average. In contrast, rural residents fell below the average for eight of them (21%).

Disparities in care aren’t confined to older age groups either. A report from the Center for Healthcare Quality and Payment Reform indicates more than half of rural hospitals don’t provide obstetric care or labor and delivery services.^[] The lack of local services both increases the distance women need to travel to obtain care and heightens the risks of complications and death for mothers and their babies.

The University of Pennsylvania’s Leonard Davis Institute of Health Economics points out that, in recent years, rural hospitals have been closing at a faster rate than urban ones.^[] “And when a closure occurs, it typically causes other local providers to shut down like those in primary or specialty care,” the author noted.

Rural areas also are not as much of a draw for healthcare workers as more developed areas may be, according to the Georgetown University Health Policy Institute, which notes that fewer than 11% of physicians in the US work in outlying parts of the country despite about 20% of the population living there.^[]

Where outcomes suffer

There is extensive literature detailing disparities in outcomes between rural and urban patients (a reflection of the quality of care they receive), along with the availability of various services and the characteristics of the populations—but there is a consistent theme: People are not doing as well health-wise outside of cities.

Moreover, people living in rural areas have higher rates of premature health issues and mortality related to a variety of conditions, including cancer, heart disease, and childhood obesity, as well as worse access to and use of preventive health services and a greater likelihood of unhealthy behaviors, according to study published in the Journal of Rural Health.^[]

How to close the gap

The Journal of Rural Health study also showed that people living in rural areas had less access to information from multiple health resources, both in-person and online. The authors say “better health information access and use help individuals improve knowledge, increase use of health services, reduce healthcare costs, adopt healthier behavioral patterns, and therefore promote health.”^[]

The Tulane University School of Public Health and Tropical Medicine has some suggestions for reducing the disparities in care between cities and outlying areas.^[]

In addition, telemedicine, which expanded dramatically amid the pressures of the COVID-19 pandemic, can help expand access to specialist care not found in rural parts of the country. This can ease certain types of interactions, like mental health treatment, postsurgical follow-ups, and consistent monitoring of chronic conditions.

And finally, rural hospitals may be able to enhance the level of care they provide by establishing relationships with larger urban centers, according to Tulane.