Access to healthcare is paramount for maintaining good health, yet individuals residing in rural areas frequently encounter significant barriers. The crucial definition of healthcare access, as highlighted in a 1993 National Academies report, is “the timely use of personal health services to achieve the best possible health outcomes.” This definition underscores the importance of not just availability, but also the promptness and effectiveness of healthcare services.
Ideally, rural communities should have seamless and reliable access to a comprehensive suite of services, including primary care, dental care, mental health support, emergency medical services, and public health initiatives. Robust healthcare access is not merely a convenience; it is fundamental to:
- Maintaining overall physical, mental, and social well-being.
- Proactive disease prevention strategies.
- Early detection, accurate diagnosis, and effective treatment of illnesses.
- Enhancing quality of life for all residents.
- Preventing avoidable fatalities.
- Ultimately, increasing life expectancy within the community.
However, rural residents often face considerable obstacles that impede their ability to secure necessary medical attention. True healthcare access encompasses both the presence of services and their attainability in a timely manner. Even when healthcare facilities exist within a rural area, several factors can still hinder access. Rural populations require:
- Financial capacity to afford healthcare, including insurance coverage recognized by providers.
- Reliable transportation to reach services, which may be geographically distant, and the flexibility to take time off work for appointments.
- Confidence in communicating effectively with healthcare professionals, especially for those with limited English proficiency or health literacy.
- Assurance of privacy and confidentiality when utilizing healthcare services.
- Trust in the quality and competence of the care provided.
This guide delves into the multifaceted issue of healthcare access in rural America, emphasizing its vital importance, the advantages it brings, and the persistent challenges faced by rural communities. We will explore:
- Obstacles to care, such as healthcare professional shortages, insurance coverage gaps, transportation limitations, health literacy deficits, and social stigma prevalent in rural settings.
- Specific access issues impacting vulnerable populations and various healthcare service categories.
- Evidence-based strategies and available resources designed to enhance healthcare access in rural areas.
How Does Limited Healthcare Access Impact Rural Population Health?
Rural areas often grapple with a lower supply of primary care physicians compared to urban centers. This disparity, documented in Supply and Distribution of the Primary Care Workforce in Rural America: 2019, means that reaching a primary care provider can be a considerable journey, especially for specialized care. Consequently, individuals may rely on local primary care for specialist needs or, regrettably, postpone or forgo essential treatment altogether. When primary and specialized care are inaccessible, emergency departments (EDs) may become the default for healthcare needs. The 2024 study, Non-Urgent Use of Emergency Departments by Rural and Urban Adults, reveals that 16% of rural adults visit the ED, compared to 13% of urban adults, with 5% of rural adults using the ED for non-urgent issues versus 4% of urban adults.
The 2014 RUPRI Health Panel report, Access to Rural Health Care – A Literature Review and New Synthesis, emphasizes that these barriers lead to unmet healthcare needs, reduced preventive care, difficulties in managing chronic conditions, and even shorter lifespans. While healthcare access is not a guarantee of perfect health, it is undeniably crucial for a community’s overall well-being and achieving optimal health outcomes.
These access challenges significantly contribute to health disparities in rural communities. For a deeper understanding of these disparities, please refer to the Rural Health Disparities topic guide.
What Hinders Healthcare Access in Rural Regions?
Distance and Transportation Challenges
Geographical distance presents a significant hurdle for rural populations, who frequently must travel farther to access healthcare, particularly specialized services. This translates to increased travel time, expenses, and time away from work. Compounding this is the scarcity of reliable transportation options. Unlike urban areas with public transit, rural areas often lack such services. With a higher proportion of elderly residents and individuals with chronic conditions requiring frequent outpatient visits, the absence of adequate public or private transportation becomes a critical barrier. The Transportation to Support Rural Healthcare guide offers resources and solutions for transportation issues in rural healthcare.
Healthcare Workforce Shortages
A major impediment to healthcare access in rural communities is the shortage of healthcare professionals. Having a consistent source of care, a key indicator of access, hinges on an adequate healthcare workforce. Measures of nonuse, reflecting rural residents unable to find suitable providers, further illustrate workforce availability challenges. For state-level strategies to address these shortages, consult What state-level policies and programs can help address the problem of shortages in the rural healthcare workforce? in the Rural Health Workforce guide.
The scarcity of healthcare professionals limits service availability. As of September 2024, 66.33% of Primary Care Health Professional Shortage Areas (HPSAs) were in rural locations. For the latest statistics, refer to HRSA’s Designated Health Professional Shortage Areas Statistics. HRSA also provides data on mental health and dental HPSAs.
Primary Care HPSAs are scored from 0-25, with higher scores indicating greater need. The map below highlights nonmetropolitan areas with primary care shortages, with darker green indicating higher HPSA scores.
Alt text: Map of US nonmetropolitan areas with primary care Health Professional Shortage Areas (HPSAs), darker green areas indicate higher shortage scores.
For more on workforce challenges and solutions, see the Rural Healthcare Workforce guide.
Health Insurance and Financial Barriers
Lack of health insurance directly restricts healthcare access. Geographic Variation in Health Insurance Coverage: United States, 2022 indicates that nonmetropolitan children and adults under 65 are more likely to be uninsured than their urban counterparts.
Uninsured Population by Urbanization Level, 2022
| Adults, ages 18-64 | Children, ages 0-17 | |
|---|---|---|
| Large central metro | 13.9 | 3.9 |
| Large fringe metro | 10.1 | 4.0 |
| Medium/small metro | 12.2 | 4.0 |
| Nonmetropolitan | 13.9 | 5.5 |
| Source: CDC, 2022 |
Healthcare costs also pose a significant barrier. KFF reports show that in 2022, 43% of adults delayed care due to cost. This is amplified in rural areas, where 12% of adults reported difficulty paying medical bills, compared to 10% in urban areas. The 2023 brief, Rural Working-Age Adults Report More Cost Barriers to Health Care, emphasizes that rural working adults face greater cost-related healthcare barriers than their urban peers.
Insurance affordability is a key concern. A RUPRI brief, Nonmetropolitan Premiums, Issuer Participation, and Enrollment in Health Insurance Marketplaces in 2022, found higher average premiums in rural counties and fewer insurer options. Medicare Advantage plans in rural areas also tend to have higher costs and fewer supplemental benefits. Changes in Marketplace Premiums and Insurer Participation, 2022-2023 notes that limited insurer competition in rural areas contributes to higher premiums.
Broadband Internet Access Limitations
Telehealth’s rise, accelerated by the COVID-19 pandemic, is hindered by broadband limitations in rural areas. Slow speeds and lack of access create a barrier to telehealth services. Computer and Internet Use in the United States: 2021 shows that 13.4% of rural households lack broadband, compared to 9.0% of urban households. For further challenges, see What are the challenges related to providing telehealth services in rural communities? in the Telehealth and Health IT guide.
Health Literacy Disparities
Health literacy, the ability to understand health information, is another crucial factor. Lower education levels and higher poverty rates in rural communities often impact health literacy. Low health literacy can deter individuals from seeking care due to communication fears and difficulties navigating the healthcare system. The Rural Health Literacy Toolkit addresses this issue. The Rural Monitor series, Understanding Skills and Demands is Key to Improvement and Who’s Delivering Health Information?, explores health literacy in rural settings. The more recent series, A New Era of Health Literacy? Expanded Definitions, Digital Influences, and Rural Inequities and Educating Future Healthcare Providers: Health Literacy Opportunities for Webside Manners, examines digital health literacy.
Social Stigma and Privacy Concerns
In close-knit rural communities, social stigma and privacy worries can deter healthcare access. Concerns about seeking care for mental health, substance use, sexual health, or even chronic illnesses due to lack of anonymity are amplified. Personal relationships with providers or facility staff can contribute to discomfort. Fear of judgment from community members further discourages seeking services like counseling or HIV testing. Identifying Challenges and Solutions for Improving Access to Mental Health Services for Rural Youth: Insights from Adult Community Members (2024) discusses stigma in rural mental healthcare. Co-locating behavioral health with primary care and community programs promoting mental health can reduce stigma, while telehealth can address privacy concerns.
Why is Primary Care Crucial for Rural Populations?
Primary care, alongside emergency and public health services, forms the bedrock of rural healthcare. Primary care providers offer a wide spectrum of services, addressing diverse medical needs. The American Academy of Family Physicians defines primary care as:
“[…] primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings…A primary care practice serves as the patient’s entry point into the health care system and as the continuing focal point for all needed health care services.”
A 2005 Milbank Quarterly article, Contribution of Primary Care to Health Systems and Health, emphasizes primary care’s role in disease prevention and health improvement. It serves as the initial point of contact, particularly vital for rural residents and minorities who may face access barriers. Benefits of primary care include:
- Preventive services and early disease detection.
- Coordinated healthcare management.
- Lower mortality rates from all causes, cancer, and heart disease.
- Reduced incidence of low birth weight.
- Improved health behaviors and overall health status.
- Lower overall healthcare costs.
Rural Healthy People 2030 highlights that limited primary care access can result in missed preventive screenings and behavioral health interventions. A 2023 Rural & Minority Health Research Center brief notes that rural areas are further from safety net primary care providers (RHCs/FQHCs), with a median distance of 7.4 miles compared to 4.4 miles in urban areas. A 2019 brief indicates that 279 rural counties lack FQHCs or RHCs, with 72 isolated from safety net primary care. For more on FQHCs, see the Federally Qualified Health Centers (FQHCs) guide, and for RHCs, see the Rural Health Clinics (RHCs) guide.
Improving Access to Primary Care for Underserved Populations: A Review of Findings from Five Case Studies and Recommendations (2023) discusses strategies like increasing provider availability, removing barriers, improving affordability, and enhancing provider-patient communication. For a broader view, see Primary Care in the United States: A Chartbook of Facts and Statistics from the Robert Graham Center.
Which Healthcare Services Are Difficult to Access in Rural Areas?
Home Health Services
Home health services are increasingly needed in rural America, but access remains challenging. A 2022 Rural & Minority Health Research Center brief indicates that 10.3% of rural areas lack any home health agency, with frontier and remote areas facing the greatest deficits. Home is Where the Heart Is: Insights on the Coordination and Delivery of Home Health Services in Rural America (2017) outlines barriers for rural home health agencies, including:
- Reimbursement and insurance complexities.
- Face-to-face and homebound status requirements.
- Regulatory changes.
- Workforce shortages.
- Time and resource demands of serving geographically dispersed patients.
- Discharge and referral process issues.
See To what extent are home health services available in rural communities? in the Rural Home Health Services guide.
Hospice and Palliative Care
Hospice and palliative care in rural areas face similar challenges to other rural healthcare services, including workforce shortages, reimbursement issues, broadband limitations, and recruitment/retention difficulties.
The Rural Hospice and Palliative Care guide addresses common questions and offers resources. Community-based Palliative Care: Scaling Access for Rural Populations (2018) in Rural Monitor discusses palliative care’s role and access barriers. Palliative Care Challenges and Solutions in Rural U.S. Communities (2024) offers further insights.
Mental Health Services
Mental health service access is a significant challenge in rural areas, often leading primary care providers to fill the gap. However, they may face reimbursement and time constraints. Rural communities experience mental healthcare provider shortages, with 61.85% of Mental Health Professional Shortage Areas in rural locations as of September 2024 (HRSA data).
Mental Health HPSAs are also scored 0-25, with higher scores indicating greater need. The map below shows mental health HPSAs in both metro (purple) and nonmetro (green) areas.
Alt text: Map of US Health Professional Shortage Areas for Mental Health, metro areas are purple, nonmetro areas are green, darker shades indicate higher shortage scores.
Rural Health Research Recap: Rural Behavioral Health Workforce (2023) summarizes research showing fewer mental health professionals in rural counties compared to urban areas.
Telehealth is increasingly used to address rural mental health service gaps, reaching rural clinics, schools, homes, and long-term care facilities. The CY 2022 Medicare Physician Fee Schedule Final Rule permanently allows Medicare reimbursement for telemental health in FQHCs and RHCs. The Telehealth and Health Information Technology in Rural Healthcare guide offers more resources. For additional mental health resources, see the Rural Mental Health guide.
Substance Use Disorder Services
Rural communities face a growing need for substance use disorder (SUD) services, yet shortages persist. Lack of medically managed withdrawal providers in rural areas is a major barrier, often leading to emergency rooms or jails becoming unsuitable substitutes. Rural–Urban Differences in Out-of-Network Treatment Initiation and Engagement Rates for Substance Use Disorders (2024) highlights lower SUD treatment initiation and engagement in rural areas.
Access to medication for opioid use disorder (MOUD) and alcohol use disorder (MAUD) is also limited. What’s MAT Got to Do with It? Medication-Assisted Treatment for Opioid Use Disorder in Rural America overviews MOUD, highlighting buprenorphine’s benefits. Practical Tools for Prescribing and Promoting Buprenorphine in Primary Care Settings suggests leveraging non-physician staff and community engagement to improve MOUD access, and recommends home induction for buprenorphine treatment. See the Rural Medication for Opioid Use Disorder (MOUD) Toolkit for more.
A 2023 Rural & Minority Health Research Center brief notes that 65.5% of rural areas lack methadone-available opioid treatment within 30 miles, compared to 12.9% of urban areas. Access is particularly challenging for rural AI/AN and Hispanic populations. Allied behavioral health workers are increasingly used to bridge the gap in mental health and SUD services.
The Substance Use and Misuse in Rural Areas and Rural Response to the Opioid Crisis guides provide resources, answer FAQs, and list model programs for SUD and opioid use in rural areas.
Reproductive, Obstetric, and Maternal Health Services
Reproductive healthcare access is typically more limited in rural areas. KFF’s Women’s Sexual and Reproductive Health Services: Key Findings from the 2020 KFF Women’s Health Survey indicates rural women are less likely to have had recent Pap tests and reproductive health discussions with providers.
Obstetric service access is a growing concern. County-Level Availability of Obstetric Care and Economic Implications of Hospital Closures on Obstetric Care (2022) reports that 113 of 148 counties losing obstetric services between 2012-2019 were rural. HHS’s Healthy Women, Healthy Pregnancies, Healthy Futures: Action Plan to Improve Maternal Health in America (2020) highlights that only 6% of OB/GYNs serve rural areas, despite 15% of the population living there. However, many rural family physicians provide OB/GYN services.
Making it Work: Models of Success in Rural Maternity Care (2020) case study emphasizes partnerships and community support for rural maternity care. The Rural Maternal Health Toolkit also addresses maternity care access.
NRHA’s Access to Rural Maternity Care (2019) policy brief overviews declining access and contributing factors, offering policy recommendations to support services. Restoring Access to Maternity Care in Rural America discusses strategies like maternity care networks, telemedicine, workforce expansion, and nonclinical partnerships. See the Rural Maternal Health guide for more information.
Oral Health Services
Oral health is vital for overall well-being. Limited dental care access in rural areas can impact academic and professional success. Oral Health in America (2021) reports fewer rural residents have dental insurance. Lack of dental professionals in rural areas is another major barrier. As of September 2024, 66.70% of Dental Health Professional Shortage Areas were rural (HRSA data). There are 4.7 dentists per 10,000 residents in nonmetropolitan areas, compared to 7.5 in metropolitan areas.
Dental Health HPSAs are scored 0-26, with higher scores indicating greater need. The map below highlights nonmetropolitan areas with dental health shortages.
Alt text: Map of US nonmetropolitan areas with dental health Health Professional Shortage Areas (HPSAs), darker green areas indicate higher shortage scores.
NRHA’s Improving Rural Oral Healthcare Access (2018) recommends rural training tracks, recruiting rural students, broad skills training, and community support for recruitment/retention. See What oral health disparities are present in rural America? in the Oral Health in Rural Communities guide.
Impact of Rural Healthcare Facility Closures on Access
Rural healthcare facility and service closures significantly impair healthcare access. Fragile rural systems are vulnerable; closures or provider departures have cascading effects. Hospital closures impact physician recruitment and C-section access, for example.
Factors influencing the impact of closures include:
- Distance to alternative providers.
- Availability of other services.
- Transportation infrastructure.
- Community socioeconomic and health status.
Travel burdens disproportionately affect low-income individuals, those without paid time off, or those with transportation limitations.
Hospital closures create substantial access issues. A Comparison of Closed Rural Hospitals and Perceived Impact (2015) identifies impacts like unstable diagnostic and emergency services, rising EMS costs, and unmet needs due to transportation barriers, disproportionately affecting vulnerable populations.
The North Carolina Rural Health Research Program’s interactive map tracks rural hospital closures since 2005, showing 106 closures and 86 conversions. Continued closures are expected due to thin operating margins. Since 1990, Rural Hospital Closures Have Increasingly Occurred in Counties that Are More Urbanized, Diverse, and Economically Unequal (2022) indicates closures disproportionately affect communities of color, impoverished areas, and the South. For a summary, see Rural Hospital Closures: 2023 Update.
Loss of emergency services is a critical concern. Improving Efficiency and Preserving Access to Emergency Care in Rural Areas (2016) discusses policies and alternative models. Alternatives to Hospital Closure: Findings from a National Survey of CAH Executives (2020) explores options to maintain access. Rural Emergency Hospitals (REHs), starting in 2023, offer a new model to maintain emergency services. See the Rural Emergency Hospitals guide.
Nursing home closures also impact rural areas. Trends in Nursing Home Closures in Nonmetropolitan and Metropolitan Counties in the United States, 2008-2018 shows 472 closures in rural counties, with 10.1% of rural counties becoming nursing home deserts by 2018. Nursing Home Closures and Trends: June 2015 – June 2019 highlights the significant impact on rural communities with fewer alternatives. Nursing Home Closures and Access to Post-Acute Care and Long-Term Care Services in Rural Areas shows longer travel distances to alternative nursing homes in rural areas post-closure.
Pharmacy service maintenance is also challenging. Causes and Consequences of Rural Pharmacy Closures: A Multi-Case Study highlights the crucial role of rural pharmacies, especially for elderly residents needing medication management.
Changes in Rural Pharmacy Presence 2023 (2024) describes vulnerable communities losing pharmacies, characterized by older populations, higher unemployment, uninsured rates, poverty, and disability rates. Locations and Characteristics of Pharmacy Deserts in the United States: A Geospatial Study (2024) notes pharmacy deserts are linked to lower education, less insurance, fewer English speakers, more disabilities, and higher minority populations. Independent Pharmacy Closures (2022) shows rural pharmacy decline between 2003-2021. See the Rural Pharmacy and Prescription Drugs guide.
Strategies to Enhance Rural Healthcare Access
Several strategies are being implemented to improve rural healthcare access:
Innovative Delivery Models
Rural Emergency Hospitals (REHs), a new Medicare provider type in 2023, aim to maintain emergency and outpatient care. See the Rural Emergency Hospital guide.
Community Paramedicine expands paramedics’ roles to provide healthcare services, described in the Community Paramedicine guide and Rural Community Paramedicine Toolkit.
Community Health Workers (CHWs) act as liaisons between providers and residents, facilitating access, as detailed in the Community Health Workers in Rural Settings guide.
Care coordination models like ACOs and PCMHs extend primary care access. Rural medical home and care coordination programs are highlighted in the Rural Health Models and Innovations section.
System Affiliations and Networks
Rural facilities may join networks or affiliate with larger systems to improve financial viability and service offerings. Trends in Hospital System Affiliation, 2007-2016 (2018) notes increasing rural hospital affiliation. The Rural Hospital and Health System Affiliation Landscape – A Brief Review (2018) discusses affiliation types and benefits like technology access, staff recruitment, group purchasing, and improved performance.
Networks enable resource sharing and collaboration. Clinically integrated networks (CINs) extend collaboration into clinical areas. Better Together: Rural Hospital High-Value Networks in Rural Monitor discusses high-value networks.
Workforce Enhancement Initiatives
Efficient workforce utilization is crucial. Strategies include maximizing professional scope of practice, using new provider types, interprofessional teams, and flexible scheduling. Access to Health Care in Rural America: Current Trends and Key Challenges (2024) highlights federal workforce programs. The Rural Healthcare Workforce guide discusses strategies like partnerships, increased pay, incentives, and telehealth, as well as state/federal policies like loan repayment programs.
Telehealth Expansion
Telehealth is a key tool for rural access, enabling specialist consultations and provider support. However, broadband access disparities exist. Geospatial Analysis of Access to Health Care and Internet Services in the US (2022) shows internet access correlates with healthcare access, but rural areas lag in both. Federal Communications Commission 2020 Broadband Deployment Report highlights rural broadband gaps.
Potential downsides include telehealth supplanting in-person care and impacting rural facility finances, as noted in Financial Effects of Remote Product Delivery: Evidence from Hospitals. A balance of telehealth and in-person care is needed.
The Role of Telehealth in Achieving a High Performing Rural Health System: Priorities in a Post-Pandemic System (2023) addresses telehealth policy. HHS offers a rural telehealth guide and policy page. The Telehealth and Health Information Technology in Rural Healthcare guide provides a broad overview, program examples, and funding resources.
Improving Healthcare Access for Rural Veterans
Travel distance to VA facilities is a major barrier for rural veterans. 2018 study found VA healthcare deserts are also underserved by non-VA providers. Frontier Health Care: Ensuring Veterans’ Access No Matter Where They Live (2024) discusses rural veteran healthcare access issues.
Access to Care Among Rural Veterans (2019) notes rural veterans’ older age and higher rates of chronic conditions and suicide. VA community-based outpatient clinics, mobile clinics, and telehealth aim to improve access. See the Rural Veterans and Access to Healthcare guide.
Healthcare Access for American Indians and Alaska Natives
AI/AN populations face unique healthcare access challenges. Health Coverage Among American Indian and Alaska Native and Native Hawaiian and Other Pacific Islander People (2023) reports higher uninsured rates for AI/AN adults and children.
The Indian Health Service (IHS) provides services, but Broken Promises: Continuing Federal Funding Shortfall for Native Americans (2018) highlights inadequate funding as a barrier. IHS services are not considered insurance. See Is access to Indian Health Service (IHS) resources considered health insurance? in the Rural Tribal Health guide. The Rural Tribal Health guide offers more resources.
Organizations Improving Rural Healthcare Access
Numerous organizations work to address rural healthcare needs and ensure essential service availability.
Private Foundation Role in Improving Healthcare Access
Private foundations support rural healthcare access through funding transportation, workforce initiatives, and innovative delivery models. Foundations’ Efforts to Improve Rural Health Care (2017) in Health Affairs highlights foundation projects. Grantmakers in Health offers resources like Improving Health Care Access: Grantmakers Share Their Experiences and Improving Health Access in Communities, Lessons for Effective Grantmaking.
Last Updated: 12/19/2024
Last Reviewed: 11/8/2024
