Written by Max Kettles
In 1999, rural Americans were 7% more likely to die than people living in cities. By 2019, the gap had tripled (Curtin & Spencer, 2021). Measured by the age-adjusted death rate, a metric that controls for differences in population age, this widening disparity reflects more than just geography. The market failures and structural inequities in the US healthcare system have marginalized rural populations, making care outside city centers lower quality, harder to access, and more expensive. Fixing rural healthcare in America requires changes in policy and the culture of medicine so that rural communities can access equitable care without going broke.
The healthcare gap between rural and urban communities is wide. Rural residents have higher mortality rates, lower life expectancies, higher rates of chronic diseases, and higher rates of chronic pain (Rural Health Information Hub, 2022). These health problems do not just affect individuals; they create broader economic costs through lower labor force participation, increased disability claims, and a heavier reliance on expensive emergency care. (Holmes, 2006)
Rural hospitals are closing at alarming rates, largely due to financial pressures that they cannot overcome. (Holmes, 2006) Most private insurers reimburse rural hospitals at the same rate as urban ones, despite rural hospitals serving far fewer patients and facing similar fixed costs. These thin margins make it nearly impossible for small rural hospitals to stay open. Without larger patient volumes to spread out expenses, even routine care can put a facility in the red (Levins, 2024).
A growing issue called “rural bypass” worsens financial problems. Rural bypass is just what it sounds like; it is when people bypass their local hospitals and travel to larger ones, and about 50% of rural patients participate (Levins, 2024). Many patients have concerns about limited services in local hospitals, while in turn, urban hospitals market aggressively to rural areas, offering specialized care and better reputations, drawing needed patient volume, necessary to keep hospitals afloat, away from rural hospitals. However, rural bypass is less prevalent for patients with strong primary care relationships nearby, highlighting community-level healthcare benefits (Levins, 2024).
A big part of the rural healthcare crisis comes down to market failures. Hospitals in small towns cannot survive if their value is only measured in profit. They might be essential to the community, but they do not bring in enough patients to cover fixed costs. On top of that, it’s hard to convince doctors and nurses to move to rural areas when the pay is lower, the work is more taxing, and they are already deep in student debt (Holmes, 2006).
Even when care is available, the system often rewards short-term fixes instead of long-term health. It makes more money to treat problems after they happen than to prevent them in the first place, which explains why chronic conditions hit rural communities so hard (NRHA, 2024).
Rural patients also suffer from failures in pharmaceutical pricing.
With little government regulation in place, drug manufacturers take full advantage of their market power. They price-gouge products to take advantage of those managing chronic conditions. Rural residents face both higher rates of chronic illness and higher rates of poverty, making them extremely vulnerable to these high prices. People are forced to either lower or no doses of their medications when it is not covered by their insurance. The result is worsening health conditions in rural communities that lead to an increased need for emergency services, putting even more strain on the system (Melton, 2025).
The U.S. government has attempted to address these issues in the past, but the outcomes have not resulted in any major progress. Past programs have mainly provided monetary support to failing rural health sectors. The Critical Access Hospital (CAH) program sends funding to small hospitals considered essential to rural areas. Similarly, the United States Department of Agriculture’s Emergency Rural Health Care Grants help pay for upgrades to rural healthcare facilities. The U.S. has also provided more support for telehealth and rural health clinics, but the upgrades and financial support to the programs have not made a dent in the overall crisis.
Throwing money at the system does not work if it is not structured to support small hospitals and long-term care in rural areas.
Other countries with remote populations have found ways to make rural healthcare work. In Norway, telehealth has been a major focus. Patients can access doctors from anywhere, which cuts down travel and helps with early intervention. Norway found success through investments in AI image analysis and teleradiology (Gullslett, 2024). Scotland uses mobile health units that bring care directly to people in rural areas. They mainly offer primary care, but can handle emergencies too (Iqbal, 2022). The Netherlands takes a more local approach, with municipalities directly overseeing rural health services. That has helped build trust in healthcare systems and follow through on preventive care (Maarse, 2018).
Across all three countries, the common focus is on constant access that gives patients more agency over their health choices, leading to a healthier lifestyle that is less costly on the health systems later down the line.
One reason these programs work is because the countries are invested in making healthcare accessible and preventive. Most European countries use publicly funded systems instead of relying on private insurance. That gives their governments more control over costs and lets them prioritize public health outcomes. The structure creates incentives to keep people healthy, not just treat them after they are sick. It also helps cut down on high drug prices and administrative waste, which are major problems in the U.S.
In contrast, the American system often puts profit before access, especially in rural areas. Even when good ideas are introduced here, they do not get far because the system is built around reactive care. That is, part of the reason rural health reform efforts in the U.S. have fallen short: even smart policies cannot succeed when they are layered onto a system that prioritizes treatment over prevention and profit over access.
I believe switching to a universal, prevention-focused healthcare system would help both rural and urban areas. But rural America is not Europe. In many small communities, people pride themselves on taking care of things independently, and that mindset makes them less likely to see a doctor, even when something is wrong. That mindset did not appear out of nowhere. It results from years of limited access, poor outcomes, and feeling left out of the system (Orgera, 2023). When people do not trust that care will help them, they avoid it. That leads to worse health habits, fewer checkups, and chronic conditions that aren’t treated until they become serious.
Much of this comes down to information or the lack of it. In many rural families, there has been a gap in healthcare knowledge passed down across generations. That makes it harder to know when to seek care, what to ask for, or why preventive habits matter (Chen, 2019). Economists call this information asymmetry. When one side has more or better information than the other, it leads to worse decisions and inequitable outcomes.
Poverty makes things even harder. When people struggle to pay for rent, groceries, or keep the lights on, they cannot afford to access healthcare. A doctor might recommend eating better or coming in for regular checkups, but for many people, that’s not realistic given the immense stress they are under, keeping themselves and their families afloat (Orgera, 2023).
Fixing rural healthcare is not just about funding or policy. It’s about recognizing the two forces working against progress: market failures and cultural barriers. Reform will not work unless it addresses both. That means designing systems that support rural providers and rebuilding trust with the people they serve. There is no one-size-fits-all answer, but any serious attempt to improve healthcare in this country has to start by listening to the rural communities that have been left out for too long.
To address the problems, the government should consider investments in rural care that follow the success stories in Europe. In the long run, investments in rural health care will pay for themselves through the decreased cost of care per capita. The government should restructure our funding towards rural health services to encourage healthcare professionals to practice in underserved communities and incentivize efficient care, following the polices across Europe, specifically the Netherlands. Investments need to have additional focus on community-based efforts that involve local leaders with the goal of increasing health literacy and shifting the focus to preventive care. Additionally, efforts need to be made to expand our telehealth network and lower prescription drug prices. These interconnected efforts will make healthcare more affordable to rural patients and decrease the financial burden our current rural healthcare system has on our economy.
References
Chen, X., Orom, H., Hay, J. L., Waters, E. A., Schofield, E., Li, Y., & Kiviniemi, M. T. (2019). Differences in Rural and Urban Health Information Access and Use. The Journal of Rural Health, 35(3), 405–417. https://doi.org/10.1111/jrh.12335
Curtin, S., & Spencer, M. (2021). Key findings Data from the National Vital Statistics System. https://www.cdc.gov/nchs/data/databriefs/db417.pdf#page=3
Holmes, G. M., Slifkin, R. T., Randolph, R. K., & Poley, S. (2006). The Effect of Rural Hospital Closures on Community Economic Health. Health Services Research, 41(2), 467–485. https://doi.org/10.1111/j.1475-6773.2005.00497.x
Iqbal, A., Anil, G., Bhandari, P., Crockett, E. D., Hanson, V. M., Pendse, B. S., Eckdahl, J. S., & Horn, J. L. (2022). A Digitally Capable Mobile Health Clinic to Improve Rural Health Care in America: A Pilot Quality Improvement Study. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 6(5), 475–483. https://doi.org/10.1016/j.mayocpiqo.2022.08.002
Levins, H. (2024, April 25). Exploring the Policies That Are Closing Rural Hospitals. Penn LDI. https://ldi.upenn.edu/our-work/research-updates/exploring-the-policies-that-are-closing-rural-hospitals/
Maarse, H., Jansen, M., Mariëlle Jambroes, & Ruwaard, D. (2018). The Netherlands. Nih.gov; European Observatory on Health Systems and Policies. https://www.ncbi.nlm.nih.gov/books/NBK507329/
Melton, T. C., Ryan, M., Stallings, A. M., Park, S. H., Lanier, C., Ballou, J. M., & Rosenthal, M. (2025). Through the lens of rural patients and pharmacies: A content analysis of state level pharmacy benefit manager regulations and policies. Exploratory Research in Clinical and Social Pharmacy, 18, 100595. https://doi.org/10.1016/j.rcsop.2025.100595
Monika Knudsen Gullslett, Ronchi, E., Lundberg, L., Larbi, D., Lind, K. F., Tayefi, M., Phuong Dinh Ngo, Tyrone Reden Sy, Adib, K., & Hamilton, C. (2024). Telehealth development in the WHO European region: Results from a quantitative survey and insights from Norway. International Journal of Medical Informatics, 191, 105558–105558. https://doi.org/10.1016/j.ijmedinf.2024.105558
NRHA. (2024). About Rural Health Care | NRHA. National Rural Health. https://www.ruralhealth.us/about-us/about-rural-health-care
Orgera, K., Senn, S., & Grover, A. (2023, September 27). Rethinking Rural Health. Research and Action Institute. https://www.aamcresearchinstitute.org/our-work/issue-brief/rethinking-rural-health
Rural Health Information Hub. (2022, November 28). Rural Health Disparities Introduction – Rural Health Information Hub. Ruralhealthinfo.org. https://www.ruralhealthinfo.org/topics/rural-health-disparities20240912-USDA-RD-ME-SDS-CADeanHospital-0004. (2025, May). Flickr; 20240912-USDA-RD-ME-SDS-CADeanHospital-0004 | Northern Light… | Flickr. https://www.flickr.com/photos/usdagov/54152281749/