The State of Rural Public Health: Enduring Needs in a New Decade

Abstract

Public health in the rural United States is a complex and underfunded enterprise. While urban-rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties.This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers.Finally, we offer 5 population-based "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

FIGURE 1—

Trends in US Premature Mortality at Birth in Urban vs Rural Counties Source. Years of potential life lost (YPLL) before age 75 years per 100 000 population (age-adjusted) data from County Health Rankings. Per-capita personal income quartiles from Bureau of Economic Analysis (middle 2 quartiles not shown). Rural data using Rural–Urban Commuting Area definitions from US Department of Agriculture (4 and above coded as rural).

FIGURE 2—

Employment- and Age-Adjusted Mortality During and After the Great Recession, by Detailed Urban–Rural Classification Source. Bureau of Labor Statistics and CDC Wonder. Detailed urban rural definitions from National Center for Health Statistics. Note. Higher numbers indicate better employment outcomes and worse mortality outcomes by county relative to the value in 2008 (where index = 100).

FIGURE 3—

Per-Capita Spending on Social Services by Local Governments, by Rurality, 1972–2012 Source. US Census Bureau. Rural–Urban Commuting Area codes from the US Department of Agriculture. Note. Spending adjusted per capita and for inflation. Includes direct spending; does not include capital or construction or transfers.

FIGURE 4—

Mean Per-Capita Spending in Local Health Departments, by Rurality, 2008–2019 Source. National Association of County and City Health Officials. Note. Figures were calculated using average per-capita expenditures, adjusted for inflation using the Bureau of Economic Analysis State and Local Government Deflator. Bars represent 95% confidence intervals. Excluded are local health departments with inflation-adjusted per-capita spending below the first percentile or above the 99th percentile, by year and category. Also excluded are jurisdictions without LHDs.