Preface: Why Rural Health Demands a National Conversation
This essay kicks off a four-part series titled Rural Health Resilience, which explores the state of rural health in America through the eyes of a surgeon, policymaker, and entrepreneur. My experience ranges from caring for patients referred from rural hospitals as a surgical intern, to treating them as a heart and lung specialist in VA hospitals and academic medical centers, to representing their interests in Washington as a senator from Tennessee. Additionally, I’ve been involved in creating companies like Aspire Health, Main Street Health, and Monogram Health—organizations that serve hundreds of thousands of rural Americans in their homes and communities. My work as a surgeon in remote clinics across sub-Saharan Africa has further underscored the profound impact of geography on health outcomes.
Rural America is often overlooked, yet its health is deeply intertwined with the nation’s overall well-being. Traditional financial, organizational, and delivery models that apply in urban contexts do not translate effectively to rural settings. A tailored approach is essential. Over the course of this series, I will share potential solutions to the numerous challenges rural health faces.
The Four Pillars of Rural Health
- The Rural Health Crisis: How We Got Here—and Why It Affects Us All (this first essay)
- Closing the Distance: Fixing Access to Care in Rural America
- What Counts: How Technology Can Transform Rural Health
- A Healthy Return: How Investing in Rural Care Is Good for America
The Rural Health Crisis: How We Got Here—and Why It Affects Us All
A Crisis in Plain Sight
My awakening to the vulnerabilities within rural health came not through policy papers but through individual patients. One such patient, a 52-year-old farmer from western Tennessee, epitomized the struggle. Stoic and resilient, he only sought medical help when he could no longer ascend the stairs of his tractor. By the time he reached me—a heart specialist—he was battling advanced heart failure. The nearest cardiologist was two counties away, and his local hospital had closed. Precious time, and ultimately his health, was sacrificed due to access barriers.
This man’s story is, regrettably, not unique. Nearly 60 million people, or one in five Americans, are embroiled in a slow-moving health crisis. The definition of “rural” may differ slightly among agencies, but generally includes non-metropolitan counties characterized by lower population density and geographical isolation from urban centers. These communities, ranging from Appalachia to the Mississippi Delta, are central to America’s food, energy, and cultural identity. Even densely populated states like California, New York, and Florida harbor significant rural regions with access and health outcomes resembling traditionally rural states.
Statistical Realities: Geography as Destiny
The numerical disparities paint a grim picture:
- Rural Americans are 20–30% more likely to die from major health issues like heart disease and cancer.
- They face a 50% higher risk of premature death compared to their urban counterparts.
- Maternal mortality rates are 60% higher in rural settings and more than double for Black and Native women.
- Over 65% of rural counties lack a psychiatrist, while 80% do not have an inpatient detox facility.
- Since 2010, more than 130 rural hospitals have shut their doors, with over 600 more at risk.
These statistics are not just figures. They translate to lives cut short, families left bereaved, and communities left in disrepair.
The Hidden Health Gaps
Rural health disparities extend beyond mere access to medical facilities; they are intricately linked to social determinants of health, including housing, education, transportation, food access, and economic stability. Dr. Carrie Henning-Smith from the University of Minnesota aptly asserts, "The biggest drivers of rural health inequities are not medical. They are structural." Rural residents face challenges such as substandard housing and limited transportation options. These social risks amplify clinical risks, creating a complex web of factors contributing to poor health outcomes.
In essence, many rural Americans are not dying due to a lack of medical professionals; they are facing a much deeper struggle rooted in socio-economic challenges long before they encounter the healthcare system.
Aging, Isolation, and Infrastructure Breakdown
Rural America is aging at an alarming rate; nearly one in five rural residents is over 65. While younger generations migrate to urban centers, older individuals are often left behind, managing multiple chronic conditions without access to adequate healthcare services or resources. Dr. Tim Slack from Louisiana State University highlights a troubling trend: "What we’re seeing is a slow erosion of the systems that support health—economic, medical, and civic."
Though telehealth offers a promising solution in a post-COVID world, access remains an issue. Millions of rural residents are still cut off from virtual care due to factors such as lack of broadband, affordability, and digital literacy.
Real Stories, Real Stakes
I’ve witnessed the overwhelming reality of rural health firsthand. At Monogram Health, we care for patients suffering from advanced kidney disease without access to dialysis centers. Aspire Health focuses on palliative care for rural seniors facing life-limiting illnesses, many of whom are homebound and socially isolated. Through Main Street Health, we have built a primary care model deploying local health navigators in 22 states, tailoring our approach to meet patients where they are.
These initiatives began as innovative ideas, tailored to rural needs, and have now demonstrated scalable solutions. They underscore that rural healthcare can succeed when developed with intention, sustainability, and an earnest commitment to understanding local community needs.
A Diverse Community with Shared Challenges
Rural America is not monolithic; it is diverse in economic, racial, and cultural terms. A coal town in Appalachia faces different challenges compared to a farming community in California’s Central Valley or a tribal health center in South Dakota. Yet, while unique vulnerabilities exist, overarching challenges are universally shared across these communities.
Dr. Monnat emphasizes the necessity of recognizing the resources inherent in rural populations: "We often treat rural as a category of deficiency. But the truth is that rural communities have enormous assets—tight-knit networks, cultural resilience, and deep place-based knowledge."
A Call to See—and Then to Act
The rural health crisis demands our attention and action, not merely as a side note but as a focal point of national discussion. Ignoring this issue not only threatens the vitality of rural communities but also affects the overall social fabric and economy of the nation.
The emerging opportunities to improve rural health also serve as an avenue for broader healthcare advancements. This series will delve deeper into how existing data and innovative models can offer a road map for actionable solutions.
What’s Next
In the following essay, we will scrutinize the specific hurdles that restrict rural Americans from receiving adequate healthcare and explore innovative efforts aimed at closing this gap. From workforce shortages and transportation issues to mobile health units and broadband access, we will identify what’s amiss and what’s promising in the quest to improve rural health.
Lastly, if we cannot provide effective healthcare for the 60 million Americans who sustain our nation—who precisely are we serving?
