Health Disparities in the U.S. - Part 3

Why are there chronic health disparities in the United States? This is the third post in a series exploring this question through review of a specific contributing factor. The first two entries looked at the influence of health insurance access and socioeconomic status on health outcomes. The topic of this post is geographic area. Rapid industrialization, transition from family to large-scale commercial farming and associated population migration from rural to urban areas has contributed to inadequate healthcare facilities/services, limited insurance coverage options and health disparities in the rural United States.

Demographics and context

According to the Census Bureau, rural areas contain 19.3 percent of the total U.S. population, totaling 60 million people. A significant majority (80%) of U.S. residents live in urban areas. This reflects a long-term population shift from rural to urban areas that started in the early 20th century. Rural residents are generally older (median age: 51), with more than 20 percent of the population in many counties being 65 or older, less likely to have a college degree (19 percent) and are much less ethnically diverse (79% white) than those in urban areas (44% white).

The number small family farms have declined significantly over the past century with the rise of large-scale, factory farming. A report from the United States Department of Agriculture cited a decrease of 2 million farms between 1935 and 2012, with the same total acres of farmland being held in far fewer, much larger farming operations. The total rural labor force has declined significantly in recent years with a net 277,000 reduction between 2013 and 2017. Declining economic opportunity is also reflected in overall poverty rate (16.4 percent vs. 12.9 percent in urban areas) with the percentage of children growing up poor (25 percent vs. 20 percent in urban areas).

Limited healthcare facilities, personnel and resources

Residents of rural areas are more likely to be uninsured (12.3%) than those in urban areas (10.1%) and states with substantial rural populations have been less likely to pursue Medicaid expansion as outlined in the Affordable Care Act. For those able to afford subsidized private insurance, the number of available insurance carriers has declined in many rural areas with large portions of Alaska, Mississippi, Alabama, North Carolina and the entire state of Wyoming having only 1 participating carrier in the state Affordable Care Act Marketplace.

A review by Forbes found rural areas had around 20 less total physicians per 10,000 people than in urban areas. The disparity is even worse for specialty care with only 30 specialists per 100,000 people in rural areas contrasted with 263 specialists per 100,000 urban residents. 60 percent of rural residents live in an area without sufficient mental health providers to meet the needs of community and over 50 percent lack a provider licensed to provide treatment for opioid addiction. Access to emergent care has also declined with 112 hospital closures in rural counties over the past decade.

Health disparities between rural and urban residents

Rural communities are in general, less healthy and have worse health outcomes than residents in suburban and urban areas. For example, rural areas have higher rates of serious chronic diseases including heart disease, cancer, respiratory illnesses and stroke and significantly more unintentional injuries. Rural residents are also more likely to use tobacco and have been disproportionately impacted by the opioid epidemic, with a rate of overdose deaths 45% higher than in urban areas. These disparities are also reflected in mental health illnesses and outcomes, with a higher incidence of depression, reported economic, mental and family-related distress and suicide.