WORKING TO ADVANCE THE HEALTH OF RURAL AMERICANS: AN UPDATE FROM THE ABFM

Over the past 5 decades, existing disparities between the health of rural and urban Americans has grown across a range of outcomes. According to the Centers for Disease Control and Prevention (CDC),1 the 46 million people living in rural America are not only increasingly more likely than urban counterparts to die from each of the top 5 sources of adult mortality—heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke—but also experienced a widening gap in child and adolescent death rates between 1999-2017.2 James and colleagues describe a “rural mortality penalty,” first emerging in the mid-1980s, and rapidly growing higher in the subsequent decades to which 448,000 excess deaths can be attributed by 2007.3 Many rural areas have longstanding disparities compared with urban areas in social determinants of health4,5—poverty, intimate partner violence, access to services, economic opportunity, homelessness—and these are often concentrated in rural areas with high percentages of minorities.6 New challenges such as the opioid epidemic and increasing multimorbidity have compounded these longstanding disparities in social determinants while access to health care services in rural areas is also in decline. For example, a recent paper found that from 2005 to 2015, the supply of primary care physicians, relative to the population, decreased with rural counties declining more on average than urban counties (–7.0 per 100,000 population vs –2.6 per 100,000 population).7 Additionally, 162 rural hospitals closed between 2005-2019 in an accelerating fashion.8 Access to specialty health care services remains a significant challenge for rural populations.