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INTRODUCTION

Rural America is home to approximately 60 million persons, or about 20% of the nation’s population.1 This population is widely distributed, with the U.S. Census Bureau estimating that 97% of the U.S. landmass is rural. The rural economy is critical to the nation. Farm products alone account for about 1% of gross domestic product and 1.4% of national employment, without considering the effects of food processing or other rural industries (2015 data).2 Culturally and environmentally, rural America is both broad and diverse, with settlement patterns ranging from the dense farms and small towns of the South and Midwest to the far-flung ranches and forested areas of the West, and cultures ranging from Appalachia through communities at the Mexican–American border. Devising public health strategies across this broad sector of the country is complex and requires both detailed local knowledge and national policies that are sensitive to rural differences.

While the population of rural America is equivalent to that of a European nation (e.g., Italy has 59 million residents),3 rural populations and issues have often been an afterthought within the U.S. health policy community. As a consequence, rural residents experience higher age adjusted mortality rates than their urban peers, a disparity that is particularly acute among rural minority populations. A long history of declining health services availability, coupled with less favorable social determinants of health, is key to this disadvantage. In the sections that follow, we explore how rural America is demarcated from urban America, historic attempts to address service disparities, the current status of health in rural areas, and the outlook for future improvement in rural health.

DEFINING RURAL AMERICA

Rural communities are diverse and varied in their occupational makeup, population density, demographic composition, natural landscapes, and economic stability, which complicates analysis of health and healthcare issues. In addition, understanding “rural America” can be challenged by the variety of definitions used when talking about “rural.” The three most commonly used definitions each use a different geographic scale and set of metrics, and consequently include different populations. These include, respectively, Census block classifications, Census tract classifications, and county classifications. There are multiple operational definitions of the rural–urban continuum, most of which have been defined by federal agencies. Common threads across these definitions are population density and geographic isolation, although some definitions like the Rural Urban Commuting Area (RUCA) codes take into consideration other factors like local workplace commuting patterns.

The U.S. Census Bureau defines rurality by exclusion: the spaces and persons not classified as urban are considered rural.4 Urban is defined by population density, following the concept that rural implies a more dispersed residential pattern. “Urbanized areas” are contiguous blocks and/or tracts with a population density of 500–1000 persons per square mile in each block and a population of 50,000 or more in the total group of blocks. “Urban clusters” are similarly defined at the ...

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