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.

The United States has surpassed 330 million in population, with more than 65 million living in rural jurisdictions.¹ There is a well-described urban–rural divide in the United States, where rural residents tend to be sicker and poorer and to have worse health behaviors than do their nonrural peers.^2–8 Rural challenges are not uniform and are complicated by geographic characteristics—for example, rural Appalachia looks quite different than the rural deep South or frontier areas in the Northwest.^2,5,6 Race, too, complicates the issue.^2,3,7 Disparities across race/ethnicity interact with rurality to create regional patterns of inequality and inequity across the United States.^9,10

In this article, we highlight the profound, systems-level issues that constitute the state of rural public health from the 1980s, through the onset of the Great Recession in 2007, until the present day. We particularly consider the context of an underfunded public health system, which is highlighted within the context of readiness for and response to the COVID-19 pandemic of 2020. We include analyses of differential gains in potential life years across the United States, the lack of recovery after the Great Recession in public sector investment in the rural United States, and examinations of the revenue and spending patterns among the nation’s 1200 rural local health departments (LHDs), using urban–rural definitions derived from the Centers for Disease Control and Prevention (CDC) and US Department of Agriculture (USDA).^11,12 We follow the descriptive overview of the state of rural public health with 5 recommendations on how to build up and enhance rural public health in the United States and consider implications on implementation of these recommendations for the overall field.

PREMATURE MORTALITY: RURAL VS URBAN

Specific US subpopulations have experienced rising mortality during the last decade leading to the first declines in life expectancy in modern history.^13,14 Data on premature mortality trends have consistently shown disparities between rural and urban counties in the United States (Figure 1). Years of potential life lost (YPLL) estimates the average number of years a person would have lived had they not died before age 75 years and is expressed as number of lost years per 100 000 people. By examining trends in YPLL at the county level, we can more accurately calculate disparities between rural and urban localities.¹³

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.¹⁵ Per-capita personal income quartiles from Bureau of Economic Analysis (middle 2 quartiles not shown).¹⁶ Rural data using Rural–Urban Commuting Area definitions from US Department of Agriculture (4 and above coded as rural).¹¹

Figure 1 shows that from 2005–2007 to 2015–2017 the ratio of YPLL in rural versus urban counties has increased from 1.23 (8640/7000) to 1.31 (8771/6706). While YPLL differs significantly across states (Appendix Figure A, available as a supplement to the online version of this article at http://www.ajph.org), some of the gap between urban and rural premature mortality during this time period may be attributable to differences in the economic status of the population in urban versus rural areas more generally.^4,7,9,13,14 Not all rural areas contributed equally to the widening urban–rural mortality gap. Differences are apparent especially when comparing outcomes in the highest quartile of per-capita income (“high income”) versus the lowest quartile of per-capita income (“low income”). In 2005 to 2017, low-income rural areas had slower reductions in mortality than low-income urban areas. Conversely, high-income rural areas faced rising premature deaths since 2005, while high-income urban areas experienced declines in premature deaths. In addition, there is a demographic component in these YPLL differentials as high-income rural areas have a 10% lower proportion of Hispanic inhabitants than low-income rural areas where Hispanics make up roughly 30% of the population. Both high-income and low-income rural areas have a similar proportion of Black residents (13%).¹⁷ The uptick in premature mortality in high-income rural areas and the slower rate of YPLL improvement in low-income rural counties compared with all other local jurisdictions since 2005 foreshadows rural areas being left behind in the 2 decades that follow.

Indeed, the fallout of the Great Recession hit rural jurisdictions particularly hard (Figure 2). The Bureau of Labor Statistics reported a precipitous decline in employment through 2009 for the whole country and sustained job growth and general recovery economic recovery since. However, Figure 2 shows that the economic recovery has been much more robust in metropolitan and urban areas. Postrecession decreases in mortality were disproportionately achieved by urban areas, whereas in the postrecession period, rural areas have had significantly higher rates of excess deaths for the 5 leading causes of death—heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke.² One exception to this general trend is opioid deaths, which since 2016 have been hitting the urban United States harder than the rural United States.²⁰

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.^18,19 Detailed urban rural definitions from National Center for Health Statistics.¹²

Note. Higher numbers indicate better employment outcomes and worse mortality outcomes by county relative to the value in 2008 (where index = 100).

A HISTORIC LACK OF INVESTMENT IN RURAL INSTITUTIONS

The clinical care and mortality disparities outlined here and elsewhere in the literature are only 1 part of the urban–rural divide.^7,8 Rural communities also face disparities related to investments in the social determinants of health. A growing body of research suggests that health can be driven in large part by factors beyond access to clinical care, including housing, education, access to healthy foods, and a host of other social factors. Increases in local-level spending on these social services are associated with better population health status.²¹ It is therefore important to note the extent to which rural communities are experiencing disparities in public spending for social services and the social determinants more broadly (Figure 3). For most of the social services shown in Figure 3, per-capita spending in urban areas outstrips spending in rural areas. A gap in per-capita spending is especially notable given the potential returns to scale for spending done by urban governments serving communities with large populations.

FIGURE 3—

Per-Capita Spending on Social Services by Local Governments, by Rurality, 1972–2012

Source. US Census Bureau.²² Rural–Urban Commuting Area codes from the US Department of Agriculture.¹¹

Note. Spending adjusted per capita and for inflation. Includes direct spending; does not include capital or construction or transfers.

Local funding for health and social services is determined in large part on the basis of an area’s overall wealth, tax base, and fiscal policies. A major challenge facing many rural communities is a low and declining tax base.²³ Without meaningful growth in the resources available to support public programs such as social services, public health, or clinical care access, it is challenging to expect local governments to be able to meaningfully invest in these areas. One mechanism that federal and state governments can use to help address differences in local-level resource availability is intergovernmental transfers, which are payments from one government to another. These intergovernmental transfers can be in various forms such as grants, categorical or programmatic support for critical areas such as public health (e.g., from CDC to states, then to LHDs), housing (from the Department of Housing and Urban Development to states, counties, or cities, and often on to housing or community development departments), the environment (from the Environmental Protection Agency), or others. Rural communities have not tended to enjoy parity in their intergovernmental transfers with their more urban peer communities, in terms of total or per-capita revenues (Appendix Figure D). This is despite the fact that rural communities with smaller tax bases may be more reliant on intergovernmental transfers as larger proportions of their budget.²⁴ These intergovernmental allocation decisions have important equity implications for rural populations given the importance of intergovernmental transfers to overall resources for public health, including public health departments.

CHALLENGES TO RURAL HEALTH DEPARTMENTS

Governmental public health in the rural United States has held a critical position, historically, as among a rural community’s most important providers of protective inspections, population-based health services, and safety-net clinical health care. Before the Hill–Burton Act of 1945, which strove to better fund clinical health care in the United States, rural health care was inconsistently funded, largely relying on individual clinical practices, private rural hospitals, and scantly available basic safety-net services.²⁵ Health departments began to fill part of that health service gap and, even after the growth of federally qualified health centers and the passage of the Hill–Burton Act, funding for clinical care remained inconsistent and, thus, local public health departments in rural jurisdictions have largely had continued responsibility in ensuring reliable and sustainable clinical care services.

Since the early 1970s, national leaders and institutions in governmental public health have recommended that local LHDs discontinue direct provision of clinical care and leave that to other governmental entities and the now-emerged private health care sector.²⁶ This call, to divest clinical services from health departments and have health departments focus on population-based services, was first issued in 1973 and has been repeated at least once per decade since.²⁶ This call has created a stigma in the public health community²⁵ for LHDs that are functionally clinic-lookalikes. These LHDs tend to be more heavily staffed by nurses and other clinicians and have the majority of their dollars and activities going toward clinical prevention services versus population-based prevention, surveillance, inspections, or regulation.²⁷ Many LHDs across the country have indeed shifted to more population-based service provision but often still provide certain clinical services in traditional public health areas, including tuberculosis screening and treatment, immunizations, and screening and treatment of HIV and other sexually transmitted infections.⁴ Other types of clinical care, especially around primary care and maternal and child health, are still frequently offered by LHDs that serve jurisdictions with limited availability of clinical care and thus where LHDs remain among the providers of last resort, particularly rural and small health departments in the South.⁷ In some rural communities, if an LHD were to fully divest its clinical services, those services would functionally be unavailable through any other sources.

There are more than 2400 LHDs in the United States, about half of which are rural. These rural health departments look quite different than their urban and suburban LHD peers. Rural LHDs tend to have fewer staff and larger geographic jurisdictions to cover, which compound staff size and travel time issues. Even though rural health departments spend as much or more per capita than do their more urban health department peers, in general, they suffer from significant economies of scale challenges (Figure 4 and Appendix Figure C). There are significant fixed costs for operating a health department of any size. Paying for basic infrastructure is challenging in rural communities—not to mention maintaining the capacity to provide the nationally recommended full suite of essential public health services.²⁹ Offering comprehensive protective inspections, population-based surveillance and prevention, and also clinical care may be out of reach for a rural LHD with just a few staff. In addition, rurality and small population size served are not entirely concordant in that not all small health departments in the United States are rural, though most rural LHDs are small.³⁰ Some rural areas are not served by an LHD at all, but rather by a regional or state health department.

FIGURE 4—

Mean Per-Capita Spending in Local Health Departments, by Rurality, 2008–2019

Source. National Association of County and City Health Officials.²⁷

Note. Figures were calculated using average per-capita expenditures, adjusted for inflation using the Bureau of Economic Analysis State and Local Government Deflator.²⁸ 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.

Operating costs for small governmental entities and concomitant infrastructure means that even when per-capita spending may appear high, total spending is typically quite modest (Figure 4, Appendix Figures A and B). While changes in and relative levels of per-capita spending may tell one story of urban versus rural resource availability for public health, total expenditures often tell another story entirely. Thus, both per-capita and total spending levels are important data points and relevant for public health system stakeholders to consider in assessing adequacy of public health funding and capacity in local communities across our nation.

Rural LHDs have a smaller staff size because of smaller budgets and populations. A challenge in these rural health departments is getting the right mix of staff to offer needed services. Smaller LHDs may face greater challenges in recruiting nurses, top executives, and midlevel managers than do medium or larger LHDs.²⁷ One of the top reasons cited for these rural LHD recruitment issues is remote geographical location, alongside pay. Small rural LHDs (or LHDs in general) are often perceived as part of the clinical care safety net.^6,25 This further complicates recruitment and retention efforts, as LHDs’ direct competition with the private health care sector has historically been a losing proposition; nurses can make some $15 000 more per year for the same job class in a private health care setting compared with LHDs.³¹ Unfortunately, no national surveys give insight into these issues specific to small rural LHDs; however, an analysis of a large-scale convenience sample of small LHD staff across the nation found similar staffing and recruitment concerns.³²

A POPULATION-BASED PRESCRIPTION FOR RURAL PUBLIC HEALTH

Rural LHDs face structural challenges in addressing the needs of populations that experience poorer health outcomes and social determinants than their urban peers and have fewer available resources to address these challenges.⁷ While the outcome is “sicker and poorer,” the factors that place many rural residents at a disadvantage relate to a diverse set of factors tied to, among others, educational opportunity, housing quality and availability, and, perhaps most importantly, community economic vitality.^{2–4,7,10,13,24} Rural areas have not seen economic recovery, workforce investment, or public sector investment concomitant with their urban peers since the Great Recession. Despite these challenges, there remain social and structural advantages in rural communities that can be leveraged to improve health and well-being. These rural advantages include high levels of social connectedness, self-reliance, and shared history.³³ Robust state and local public health systems can play a strong role in facilitating community efforts to leverage these rural strengths and assets and to help convene cross-sector partners that have influence across the social determinants of health. We offer 5 recommendations to enable the governmental public health enterprise to better support rural LHDs in their work:

1. Reduce variation across definitions of “rural” to standardize eligibility for state and federal support.

2. Foster an identified rural public health constituency to advocate for rural health issues.

3. Create a population-based prevention agenda for the rural United States.

4. Increase investments in rural public health.

5. Reduce stigma and consider individual community needs associated with LHDs providing clinical services.

Reduce Variation Across Definitions of “Rural”

There are several core issues underlying the profound, systems-level issues facing the rural public health system. One seemingly mundane, but important, issue is the lack of uniform categorization of rurality. The federal government employs several definitions of rurality, which vary widely across agencies, with state governments often using their own definitions.^7,34 Ultimately, the rationale for any rural definition is to create inclusion and exclusion criteria for the allocation of resources. To a certain extent, these definitional criteria will always be problematic as there will inevitably be communities at the periphery that are excluded from opportunities. While it is important to acknowledge and embrace the unique “flavors” of rural that exist in our diverse nation, efforts to standardize definitions for state and federal support could facilitate local efforts to secure needed funding and resources to address public health concerns as well as collectively assess performance and recognize needs specific to rural communities. Recognizing that no definition will ever be perfect, and in an effort to not oversimplify the needs of individual communities, special considerations could be made for those communities at the periphery of eligibility criteria to determine if unique factors tied to their location and population demographics justify exemption from eligibility requirements. While the use of quantitative metrics to determine eligibility is preferred, a qualitative process that respects the uniqueness of individual communities may also be necessary in certain situations. We do not make a specific recommendation about which definition to adopt (though we utilized the CDC and USDA definitions in this article),^11,12 merely that a standard definition should be adopted.

Foster a Rural Public Health Constituency

A lack of a uniform definition of what is “rural” has stymied the development of an identifiable rural public health constituency that can initiate targeted advocacy efforts.³³ Though there are state-based rural public health associations, there is no national group to which rural public health agencies exclusively belong and identify with that can work to bolster the efforts and resources of rural public health agencies and staff, as there is for the health departments for the largest urban areas through the Big Cities Health Coalition or the National Rural Health Association for rural health care issues. Clearer delineation of what is the “rural” United States can in turn lead to the establishment of an identified constituency to advocate for resources and attention to public health problems affecting rural communities. Recognition of the heterogeneity of rural communities and populations will be important in this effort. In addition, the rural constituency can create a long-term vision and action plan for rural public health. Key to success for such a movement to “champion” rural public health is a transformation of the current rural health conversation beyond access to care needs to also shed light on upstream solutions specific to rural communities and promote cross-sector collaboration and public–private partnerships. Furthermore, such a rural public health advocacy movement could adapt public health frameworks, increase availability of public health data categorized by level of rurality, and advance public health system strengthening efforts, such as the accreditation of health departments tailored to meet the needs of rural communities.

Rural LHDs engaged in advocacy for not only rural public health issues specifically but also the field of public health more broadly is good for public health, both urban and rural. Rural communities play an outsized role in our nation’s politics, and our rural public health colleagues more often work in communities that tend to be skeptical of the role of government. Thus, engaging trusted locally based rural LHDs as partners in public health advocacy more generally has the potential to advance advocacy efforts and bolster the field of public health more broadly across the nation.

Create a Prevention Agenda

The lack of rural public health–focused advocacy described previously has resulted in a lack of focus on rural population health in the national discourse. National public health advocacy organizations typically do not focus enough on population health needs among rural populations, and national rural advocacy organizations have largely focused narrowly on health care access. While rural health disparities are well documented across nearly all of the leading causes of death, inattention to upstream population-based factors in rural communities has been a likely contributor to growing rural inequities. Although attention does come to some rural public health challenges, it tends to be issue-specific, such as with the opioid epidemic. While bringing needed attention to a specific rural health challenge, for opioids this has been done through the lens of addiction stigma and lack of treatment options with no consideration of or resources toward the wider population-level public health needs.

Access to care will always remain a rural health priority. However, attention and resources are also needed for other population-level public health challenges such as increasing physical activity, access to healthy food, and building social supports aimed at long-term health outcome improvements. The creation of a rural public health constituency is critical to the future of rural public health. This constituency can leverage rural strengths and assets and build on ongoing public health advocacy efforts to establish a targeted rural public health agenda focused on upstream factors and tied to collective efficacy and social connectedness, as well as shared culture and history.

Increase Investments in Rural Public Health

Importantly, we need to revisit how our public health system is financed because it places rural LHDs at a disadvantage relative to their urban peers. It has been well documented that rural LHDs are proportionally more reliant on federal, state, and clinical revenues, while urban LHDs have proportionally more access to local revenues.²⁷ Much of this can be attributed to struggling rural economies and declining populations that make it difficult to provide tax support for local governmental agencies. However, lack of local revenue inhibits rural LHDs in their efforts to address local needs. Intergovernmental transfers from the federal, state, and local levels represent a highly relevant and logical tool for addressing this gap yet are not currently being allocated as such. Strategies to bolster rural LHD staff recruitment including loan repayment and tax incentive programs should be considered. If we believe that public health is most responsive and effective when it is controlled locally, we must ensure that resources are available locally in rural communities to address identified needs.

Reduce Stigma and Consider Community Needs

As we look toward strengthening our rural public health system, it is important to consider the national message as to what public health agencies “should” be doing. While it is reasonable to set aspirational goals to push the field away from clinical care provision and toward population-level activities, this push has resulted in a counterproductive stigma that has been associated with public health agencies providing clinical services. This in turn has created a divide among LHDs in which rural agencies providing clinical services are often seen as “lesser” public health departments.²⁵ It is important to recognize that there is significant variation in funding, organization, and capacities across LHDs and wide-ranging clinical service capacity in individual communities. Thoughtful reflection on the roles and functions of rural LHDs is needed, along with respect of local autonomy in determining what services are appropriate to meet the needs of individual jurisdictions, all while creating systems and incentive structures to move public health agencies toward national goals or standards.

In many rural communities, the LHD’s role in providing clinical services ensures the availability of critical health services that would otherwise be lacking. While the Institute of Medicine has historically considered LHD provision of direct clinical care as being far from ideal,²⁶ arguably those services are also among the most visible roles that LHDs can provide in rural communities in need of health care providers. This creates opportunities for community engagement and trust building and the opportunity to link residents to other critical public health functions and social services. And to the extent that those clinical services are reimbursable, the services often provide an important revenue source that helps to retain other public health services for their communities. If clinical services return enough revenue to more than cover expenditures and are needed within a community, it is our view that there should not be a stigma for providing these services, and we might even consider asking why LHDs are not providing them.

If, on the other hand, revenue for clinical services only partially offsets expenditures or, importantly, there are already many providers in a community, these services should be viewed in light of their “actual” cost and whether they in fact crowd out population-based services. Comparing the estimated population-level impact of clinical versus population-based services given a particular level of “net” investment (i.e., less offsetting fees or clinical revenue) would then be more relevant. We could then reasonably ask: what population-oriented activities could be done with funds supporting clinical services available elsewhere in the community? In sum, the individual context of a public health agency and the community it serves is critical to assessing the appropriate role of an LHD in the provision of clinical services.

It is our view that it is appropriate to promote greater provision of population-based services (e.g., as called for in the Foundational Public Health Services model).³⁵ However, we must also recognize that, as rational agents, many rural LHDs continue to provide clinical services for good reasons and with good outcomes. Until health care access increases in rural jurisdictions and until the legal and financial context changes, it is unreasonable to expect all rural LHDs to divest their clinical services.

CONCLUSION

Rural LHDs are distinct from their urban peer departments and their advocacy needs are unique within the public health community. As such, there is a need for more resources for rural public health as well as establishment of an identified rural public health constituency engaged in targeted rural public health advocacy initiatives. These advocacy efforts should address access to care as well as upstream population-level issues. While there are organizations that represent the clinical side of rural health and organizations that represent public health more broadly, more can and should be done to bolster the efforts and resources of rural LHDs and staff to improve population health specifically as is done for large, urban LHDs. Perhaps this is an opportunity to advance rural public health—furthering the coalition of rural LHDs and staff where their unique needs can be considered and advocacy efforts can be developed. Ultimately, advocacy efforts can help to shape public health frameworks and public health system strengthening efforts to specifically meet the needs of rural communities. Rural LHDs can play a strong role in engaging rural residents and policymakers in support of the field of public health as they can provide high-touch, high-visibility, and highly regarded services to their communities. Ultimately, efforts to bolster the efforts of rural LHDs and the health of the communities they serve has the potential to benefit public health more broadly, which in the wake of the COVID-19 pandemic in 2020 has become a national priority.