U.S. Rural Population Health and Aging in the 2020s

One in five Americans lives in rural areas, and many urban residents hail from rural backgrounds. Rural America is home to most of the nation’s natural resources and natural amenities, supplies a significant portion of the nation’s food and energy, and plays a crucial role in elections. Thus, the wellbeing of rural America is essential for the wellbeing of the country.

Rural America faces three converging demographic trends that have critical implications for wellbeing and sustainability. These trends are (1) rapid population aging, (2) declines in health and longevity among working-age adults, and (3) population loss. This article describes these trends, discusses the implications for rural America, and proposes policies to address them. Throughout, it is important to remember that these trends represent averages. The rural United States is diverse, and although some areas are facing significant health and aging challenges, others are thriving.

The Rural Population is Rapidly Aging

The U.S. population is aging, a trend occurring more rapidly in rural areas than urban areas. In 2022 (see Note 1), 20% of rural (see Note 2) residents were ages 65 or older, up from 15% in 2000. In contrast, 16% of urban residents were aged 65 or older in 2022, up from 12% in 2020 (see Figure 1). Also notable is that the working-age (ages 25–64) share of the rural population has declined from 50.6% in 2000 to 49.3% in 2022, meaning fewer working-age adults (and their future children) are available to support the tax base and provide essential services to residents across all age groups.

Figure 1.

Population Age Distribution in Rural and Urban Counties, 2000, 2010, and 2018-22.

Notes: Rural (nonmetro) and urban (metro) county delineations are based on the Office of Management and Budget metro area designations. Counties are held constant to the 2010 classification.

Source: Decennial Censuses 2010 and 2020; American Community Survey 2018-22.

Given that rural counties are home to a disproportionate share of older adults, it should come as no surprise that most “older-age counties”—counties with more than 20% of their population ages 65 or older—are in rural America. Rural counties account for nearly 85% of the nation’s 1,104 “older-age counties” (Cromartie, 2018). However, the factors that drive population aging vary in different types of rural communities. Most older-age counties fall into one of two categories: (1) regions facing chronic population loss or (2) recreation and retirement destinations with scenic amenities.

In rural persistent population loss counties, high out-migration and low in-migration of younger adults have led to higher proportions of older residents and fewer younger and working age adults. One third of older-age counties are classified as persistent population-loss counties, having lost residents between both the 1990–2000 and 2000–2010 Censuses. These counties are mainly located in remote areas of the Northern Great Plains and Corn Belt (Cromartie, 2018). In these communities, a growing share of older adults increases the demand on an already strained health care infrastructure. In addition, access to aging care, transportation, retail, and other vital services is often limited. Adapting infrastructure for better accessibility can also be difficult in places with aging facilities and limited funding for upgrades.

In another set of rural older-age counties, population aging results from the in-migration of (often affluent) retirees. These areas typically offer abundant natural amenities and recreational opportunities (Johnson and Winkler, 2015). The USDA classifies one third of older-age counties as either retirement destinations or as having recreation-based economies. These counties generally have larger populations and are located closer to major cities compared with persistent population loss counties. They are concentrated in New York state, New England, the Upper Great Lakes, central Texas, and the Mountain West (Cromartie, 2018). Although retirement in-migration can boost population growth and have positive economic and social impacts, it may also lead to affordable housing shortages, increased demand for limited medical and other services, and underinvestment in the needs of children and families (e.g., schools, childcare).

Health and Longevity Are Deteriorating Among Rural Working-Age Adults

Compounding rural population aging is the fact that rural America is losing working-age adults. Rural residents generally have worse health and die younger than their urban peers (Monnat 2020). This is true among both males and females, all age groups, and all racial and ethnic groups. Higher rural mortality rates, which began in the 1980s and worsened after the mid-2000s, are largely driven by rising rates among working-age adults (ages 25–64) (Monnat, 2020). Contemporary mortality trends in the working-age group are troubling (See Figure 2). Among both rural and urban working-age males, mortality rates declined throughout the 1980s and early-1990s. But although urban males continued to see improvements throughout the 1990s and 2000s, improvements stagnated among rural males. By 2010, rates were increasing among both urban and rural males, although at a far sharper rate among rural males. Among urban working-age females, mortality rates declined throughout the 1980s, 1990s, and 2000s before stagnating in the 2010s. However, among rural females, mortality rates remained stagnant until 2010, when they began to increase sharply. The age-adjusted mortality rate among rural working-age females was higher in 2019 than it had been in 1979. Going into the COVID-19 pandemic, the rural working-age mortality penalty was the largest it had ever been. The average 25-year-old rural male could expect to live another 50.8 years compared with 53.4 years for his urban counterpart. The average 25-year-old rural female could expect to live another 55.6 years compared with 58.1 for her urban counterpart (Abrams et al., 2021). The gap widened further during the COVID-19 pandemic. Although COVID-19 mortality rates were slightly higher in urban areas in 2020, they were much higher in rural areas in 2021 and 2022, largely due to lower rural uptake of protective behaviors, such mask-wearing and vaccination (Jones et al., 2023).

Figure 2.

Mortality Rates among Males (A) and Females (B) Ages 25–64 in Urban and Rural Counties, 1979 to 2022.

Notes: Mortality rates are age adjusted. Rural (nonmetro) and urban (metro) county delineations are based on the Office of Management and Budget metro area designations. Counties are held constant to the 2010 classification. Value labels shown for 1979, 2019, and 2022.

Source: CDC WONDER.

Well before the pandemic, numerous causes of death were contributing to the widening rural–urban longevity gap. Rural working-age adults have higher mortality rates from cancers and heart diseases—the leading causes of death in the United States. Additionally, they have higher rates of infectious diseases (COVID-19, influenza), respiratory diseases, stroke, diabetes, kidney disease, chronic liver disease and cirrhosis, suicide, transport accidents, and maternal mortality (Slack & Monnat, 2024). Since 1990, working-age death rates for most causes have either declined less in rural areas (e.g., cancers, heart disease) or increased more (e.g., suicide, alcohol-induced, respiratory diseases) (NASEM, 2021).

Just as important as the number of years remaining is the quality of life in those years, known as quality-adjusted life expectancy (QALE). Quality of life can suffer due to challenges with mobility, self-care, and daily activities, as well as pain and poor mental health. Here too, rural residents do worse than their urban counterparts, and the gap has increased over time (See Figure 3). Although QALE at age 60 increased over the past decade for urban men and women, it did not move for rural men and women (Chapel et al., 2025). The rural QALE disadvantage is further reflected in higher working-age disability rates. Based on my calculations from the 2018–22 American Community Survey, nearly 15% of rural males and females ages 18–64 reported a disability compared with 10% of urban males and females in this age group. In 100 rural counties, at least 1 in 4 males ages 18–64 have a disability (compared with 14 urban counties).

Figure 3.

Quality Adjusted Life Expectancy at Age 60 for Urban and Rural Men and Women, 1994–2000 and 2014–2020.

Note: Quality adjusted life expectancy reflects the number of years remaining in good health, defined based on mobility, daily activities, self-care, anxiety, depression, and pain and predicted from chronic diseases, body mass index, smoking, and functional limitations.

Source: Adapted from Chapel et al., 2025.

The upshot of these trends is that increasing shares of rural adults are dying in their prime working-age years and are living more of their lives in poor health, in chronic pain, and with disability than in the past (Chapel et al., 2025; Sun et al., 2024). These trends have troubling implications for an already strained rural health care system, the workforce and tax base, and the ability to provide critical services to the large and growing older adult population.

Although these overall trends are concerning, it is important to remember that the rural landscape is diverse (James, 2014). Mortality rates have risen in some rural areas over the past 30 years but declined in others (Elo, 2019; Monnat, 2020). For instance, the Appalachian, South Atlantic, and South-Central regions have seen high and rising mortality rates since 1990, while the mid-Atlantic, North Central, Mountain, and Pacific regions have experienced substantial improvements (Elo, 2019; Monnat, 2020). Health also varies between rural subpopulations. For example, the rural QALE disadvantage is pronounced for residents of the South, Black adults, and those without a bachelor’s degree. Conversely, QALE is comparable between rural and urban adults in the Midwest and among rural and urban Hispanic adults and individuals with a bachelor’s degree or more (Chapel et al., 2025). In terms of disability, whereas upwards of two thirds of working-age adults 18–64 with a disability are out of the labor force throughout much of the rural South and Appalachia, well over half of working-age adults with disabilities in the central and upper Great Plains are working (University of Montana, 2024). Rural areas with better health and longevity can provide valuable insights for policymakers on effective strategies to improve outcomes in other regions.

Rural America is Depopulating

Over two thirds of rural counties lost population between 2010 and 2020, and for the first time in history, rural America had absolute population decline, losing a net of 290,000 people (0.6%) between 2010 and 2020 (Johnson, 2023). Rural population loss results from both natural decrease (more deaths than births) and net out-migration (Johnson and Lichter, 2019). Between 2010 and 2019, the natural increase rate of 0.5% was not enough to counteract a migration loss of -1.1% (Johnson, 2020). And despite positive natural increase in rural America overall, 54% of rural counties experienced more deaths than births, primarily due to rising mortality among working-age adults from drug overdoses, suicides, alcohol-related causes, and cardiometabolic diseases. COVID-19 exacerbated rural natural decrease. From April 2020 to July 2023, a staggering 81% of rural counties reported more deaths than births (Johnson, 2024). Depopulating rural areas face inadequate tax bases, hindering support for essential infrastructure and services such as roads, water systems, health care, and education. Maintaining a vibrant economy is difficult due to fewer workers, diminished demand for goods and services, and limited opportunities for social and civic engagement.

Although trends in depopulating rural communities are concerning, some rural communities are experiencing robust in-migration that is helping to offset population loss from natural decrease. As prefaced earlier, rural retirement and high-amenity recreation areas are gaining both retirees and working-age adults in sectors that support them, such as services and health care. Many of these communities saw increased in-migration during the COVID-19 pandemic as people sought to escape urban environments, and remote work opportunities expanded (Peterson and Winkler, 2022). Between 2020 and 2022, domestic in-migration was particularly strong in high-amenity rural counties in regions like the Northern Great Lakes and the Rocky Mountains (Cromartie, 2024). Immigration has also helped to offset rural population decline. In “new immigrant destinations,” immigration, particularly from Mexico and Central America, has provided a demographic and economic lifeline to struggling rural communities facing population aging and declining labor forces (Johnson and Lichter 2016). Unfortunately, these positive contributions are frequently overlooked in contemporary immigration policy discussions. Growing rural communities face different challenges than rural population loss communities. Although they may have more stable tax bases, growing rural communities must deal with housing affordability challenges and increased pressure on natural resources, infrastructure, and services. These communities also often grapple with competition for resources and changes in land use and zoning, which can create tensions between newcomers and long-time residents.

Policy Implications of Rural Demographic Trends

Collectively, the trends described above suggest that rural America is facing increased demand for health care and older adult services and infrastructure at the very moment when large and increasing shares of rural-working age adults are disappearing from the labor force due to death, ill health, and disability. What levers can policymakers pull to both reverse these troubling working-age health and mortality trends and generate opportunities and resources critical for healthy aging in rural America?

Regarding working-age health and mortality trends, higher overall rural rates and widening rural–urban gaps across numerous diseases and causes of death suggest that there is not one underlying explanation and therefore no silver bullet. Strategies across multiple levels and dimensions are necessary.

Improving access to health care in rural areas is among the most common recommendations to address the rural health crisis. However, rural hospitals have closed at alarming rates over the past decade due to unsustainable operational costs, demand for more costly and intensive care from older and sicker patients, and higher shares of uninsured and underinsured patients (Kaufman et al., 2016). Operating margins among rural hospitals improved during the COVID-19 pandemic due to government relief funds, but those funds have dried up, and the lingering effects of the pandemic (labor shortages, inflation) mean even more hospitals are at risk of closure (Levinson et al., 2023). Health care policies, particularly Medicaid and the Affordable Care Act (ACA), are critical to sustaining rural hospitals and other facilities. Fewer rural hospitals have closed in states that expanded Medicaid due to increases in insured and reimbursement rates. Uninsured rates among rural adults under age 65 have dropped significantly since the ACA’s passage, from 23.8% in 2010 to 12.6% in 2023 (Turrini et al., 2024). Uninsured rates among rural residents are much higher in the 11 states that have not expanded Medicaid. These states are predominantly in the southern United States (where mortality, chronic disease, and disability rates are the highest), have larger shares of rural residents than expansion states, and account for about one third of rural hospitals (Levinson et al., 2023). Given the contemporary trend of rural hospital closures, it is critical for the federal government to adequately fund other types of health care facilities, including rural emergency hospitals, critical access hospitals, federally qualified health centers, and rural health clinics, each of which receive special reimbursement rates that enhance viability.

But we must think beyond health care. Despite decades of efforts to increase rural health care access, such as through the ACA and improvements in rural insured rates, the rural health and mortality penalty continues to grow. This may be because health care access accounts for only 10% of premature deaths in the United States (Kaplan and Milstein, 2019). Health care’s modest effect is astonishing considering the $4.1 trillion in annual health care spending ($12,530 per person), accounting for nearly 20% of GDP (Centers for Medicare and Medicaid Services, 2022). To be sure, equitable access to quality health care is a moral imperative. However, increasing access on its own is unlikely to improve rural population health in the aggregate because health care does not cause most of the diseases or injuries that make people sick. For this, we must look to upstream solutions.

The rural U.S. is diverse, with some areas facing significant health and aging challenges whereas others are thriving and seeing improvements in health and longevity.

Equitable access to quality health care is critical—rural residents need access to preventive, obstetric, and emergency care. However, increasing access on its own is unlikely to improve rural population health in the aggregate because health care does not cause most of the diseases or injuries that make people sick.

Social and economic policies are critical to health because they shape opportunities and incentives for individuals to make healthy choices across the life course (Montez et al., 2020). Policies and political choices are “the causes of the causes of the causes of geographical inequalities in health” (Bambra et al., 2019, p 37–38). Not only are U.S. policies in the areas of housing, income support, labor protections, and the environment (to name a few) weaker than in other high-income countries (all of which have higher life expectancy than the United States), they also vary dramatically across states (Montez et al., 2020). For instance, in predominantly rural states, tobacco taxes tend to be lower, advertising is more prevalent, and youth are less exposed to anti-tobacco messages (American Lung Association, 2015). Given this, it is not surprising that tobacco use—a leading cause of heart disease, multiple cancers, and respiratory diseases—is higher in rural areas. Policies that address the commercial determinants of health (private-sector products that harm health, such as tobacco, alcohol, sugar, and processed food additives) could go a long way to reducing numerous causes of death, obesity, and respiratory, organ, and autoimmune diseases. Policies to reduce smoking and alcohol consumption could include higher excise taxes, restrictions on advertising, and stronger regulations on where tobacco and alcohol can be sold. Policies to reduce harmful food consumption could include regulations on chemical food additives, restrictions on advertising sugary products, and eliminating government subsidies for sugar production (corn, sugar, and soy), most of which goes to big-ag (large-scale corporate multinational operations protected by lobbyists) rather than small rural family farmers. It is disingenuous to ask people to make healthier choices when far too many of our choices are filled with health-harming substances.

Federal policies also have a role to play in rural education. Education, particularly possessing a 4-year college degree, has become an increasingly important determinant of health and premature death in the United States (Montez and Bisesti, 2024). This is because higher education confers social, economic, and lifestyle advantages that manifest as a “personal firewall” that protects health even in the face of external and unpredictable threats, such as pandemics, recessions, and natural disasters (Montez and Bisesti, 2024). Lower educational attainment in rural areas strongly contributes to the rural health and mortality disadvantage. For instance, if rural education levels matched urban ones, the rural–urban gap in QALE at age 60 would be nearly halved (Chapel et al., 2025). Therefore, it is critical to ensure that rural students have access to quality primary education, are prepared for college, and have employment opportunities in rural areas to return to after college. However, for various reasons, not everyone can or should attend college. Therefore, policies that promote vocational training are also critical. The United States needs more tradespeople, especially as population aging has reduced the workforce in many trades. Rural America is home to a critical mass of talented people with the aptitude and interest to excel in high-skill trades that come with livable wages and from which workers derive meaning and purpose. Federal investments in vocational programs and support for trade-related entrepreneurship, such as through more robust investments in career and technical education (CTE) programs, community colleges, and stronger coordination between trade programs and telecommunications, semiconductor, and sustainable energy industries could stimulate economic development and population growth and improve health in rural America.

Improving health and wellbeing among rural working-age adults is key to promoting healthy rural aging. Healthy working-age adults become healthy older adults with less need for costly and intensive health and aging care services. But reversing the long-term decline in rural working-age adult health will take time. So, what can policymakers do in the short term to promote healthy aging?

First, there is a clear need to recruit workers to support aging in place, especially in the persistent population loss rural communities described above. Rural areas have nearly 35% fewer home health aides and 17% fewer nursing assistants than urban areas, driven by lower wages, job quality issues, and lack of investments in training and financial incentives for workers (Dill et al., 2023). Policies that tackle these domains, including immigration policy, could increase the rural workforce necessary to support aging populations. Related to this, proposals to expand Medicare to cover home care (coupled with strategies to increase the health and aging care workforce) could have an outsized benefit in rural communities, including for rural working-age adults caring for their aging parents. Finally, rural population aging highlights the need for age-friendly communities that support not only older adults but also working-age individuals and children (Warner & Zhang, 2022). This includes increasing access to childcare in rural areas to help attract and retain the working-age adults essential for supporting the tax base and caring for older residents. In addition, increasing access to high-speed and reliable broadband internet is essential for facilitating remote learning, work, and telehealth, which are vital for increasing rural economic productivity, promoting healthy aging, and reducing population decline.

Conclusion

The wellbeing of rural America is vital to the wellbeing of the United States as a whole. As the rural population ages and working-age adults face worsening health and die too young, rural communities are losing the workforce, tax base, and family and social connections needed to support the physical and social infrastructure and services critical for residents of all ages. Although some rural areas are thriving (including those that have attracted affluent retirees and those that have experienced robust immigration), many are struggling, highlighting the need for policies that acknowledge not only differences between urban and rural areas but also between different types of rural communities (Jensen et al., 2020; Rhubart et al., 2021).

The challenges described above demand urgent policy attention. Although ensuring equal access to high-quality health care is a moral imperative, it is insufficient on its own to improve health and healthy aging in rural America. Instead, policymakers should look upstream toward solutions that can tackle the structural drivers of health—education and vocational training investments and addressing the commercial determinants of health that are killing far too many Americans too young.

Author Note

1. The values presented for 2022 are from the 2018-2022 American Community Survey population estimates.

2. Here “rural” refers specifically to nonmetropolitan counties, whereas “urban” denotes metropolitan counties, as defined by the USDA’s Economic Research Service, which follows U.S. Office of Management and Budget (OMB) classifications. I use the term “rural” to ensure consistency throughout the article.

Funding

This work was supported by the Interdisciplinary Network on Rural Population Health and Aging, funded by the National Institute on Aging (R24AG089064, R24AG065159) and the USDA-supported Rural Population Research Network (W5001).

Conflict of Interest

None.