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Over 51 million Americans live in areas classified by the U.S. Office of Management and Budget (OMB) as nonmetropolitan, or “rural.” They comprise one-fifth of the U.S. population. The rural life holds great value in the history of the United States. For most of our country's history, rural living was practically the only way of life. Throughout the years, rural living has been seen as a noble and pure form of existence. Getting “back to the land” has long been viewed as a dream for many city dwellers. Unfortunately, when it comes to being old in a rural setting, there are many aspects which are not so sanguine.

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Rural aging reflects many of the attitudes held toward older people in our society. Some, for instance, have questioned whether very high health care expenditures on persons at the end of life are worthwhile. Similarly, when viewed from an economic sense, rural residence is expensive for both society and individuals. The costs of distance, inefficiencies of spatial dispersion, and absence of economies of scale mean that health care has difficulties supplying specialty care and services. Forty years ago, William Myernick wrote that it does not make sense for society to expend resources in supporting small, dispersed, economically challenged communities. Yet the fact is older people make up a large percentage of the population of people living in rural settings.

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The Kellogg Foundation conducted interviews with over 200 persons from different communities to assess views of rural living. Respondents viewed rural life as being primarily agricultural, as emphasizing family values with a strong sense of self-reliance, as having beautiful landscapes with animals and family farms, and as having a relaxed and friendly way of life. Interestingly, aging, or growing older and frailer, were not mentioned as common perceptions.

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Rural life is also connected to prominent American values—the dual values of self-reliance and interdependence with one's neighbors, freedom from governmental control, a slower pace of living, and the back to nature philosophy. As will be discussed, a significant movement, or “in-migration” of older people back to rural areas is occurring in part because of these values. However, the long trend of younger people moving away from rural areas and poorer and sicker older people remaining also continues. What society may be facing in the next few decades is a population of primarily older people living in large portions of the country—a population made of two subgroups, healthy active and politically motivated baby boomers who have returned to the land, and a larger group of frail elders who have lived all their lives in that environment. This development will challenge health care service providers, as well as Medicare and Medicaid.

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One of the problems in discussing rural aging is the definition of “rural.” The two most frequently used definitions used in research and policy development are the U.S. Census Bureau's use of community size and density and the OMB's designation ...

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