Identifying the Underlying Causes of Worse Negative Health Outcomes in Rural America

A study published in JAMA Cardiology found that people living in rural settings are more likely than their urban counterparts to be diagnosed with cardiovascular diseases or conditions that contribute to cardiovascular health issues, including hypertension, hyperlipidemia (high levels of lipids such as cholesterol and triglycerides), obesity, and diabetes (Liu et al., 2025).

Using responses to the 2022 National Health Interview Survey, Liu et al. found that rural adults aged 20 years or older living in rural areas were more likely to smoke cigarettes, be less physically active, and have more social risk factors than their urban counterparts, all of which likely contribute to the significantly higher rates of these diseases. The social factors considered for this research—commonly referred to as the Social Determinants of Health (SDOH)—include higher rates of poverty, lower levels of educational attainment, higher rates of food insecurity, and home ownership rates.

Most worryingly, this research found that these disparities were largest among younger adults and were almost entirely explained by social risk factors.

Liu et al. is just one of several studies over the past decades to highlight disproportionately negative health outcomes in rural populations in the United States. The story of rural health disparities is one that has not only been told but told to the point of becoming popular tropes that denigrate and belittle rural patients.

The truth is far more complex.

While the reality is that health outcomes are significantly worse in rural areas, how those areas “got there” requires a deeper dive into the real-world factors that lie outside of rural America, including (but not limited to):

• The significant decline of U.S. manufacturing jobs since the late-1970s (Harris, 2020)

• The monopolization and decline of extractive industries, such as coal, oil, and other raw materials (Freudenburg, 1992; U.S. Bureau of Labor Statistics, 2025a; U.S. Bureau of Labor Statistics, 2025b)

• The monopolization and consolidation of agriculture in the U.S. (MacDonald, 2020)

• The economic restructuring of the American economy as a result of these shifts.

In PlusInc’s last article, we highlighted how the Trump Administration’s Rural Health Transformation Program (RHTP) will fall significantly short of covering the financial losses caused by other provisions of the One Big Beautiful Bill Act (OBBBA). The absolute truth is that rural America has long been neglected by the federal government and businesses, despite the near-constant refrain that the jobs in rural America are the backbone of the American economy.

As with most aspects of living in rural America—particularly areas that are not only rural, but geographically isolated by mountains, deserts, or a lack of potable water and arable land—the reality is that everything takes time.

As an example: 

During the COVID-19 pandemic, schools and healthcare providers were tasked with immediately transitioning from in-person to virtual delivery models. What was quickly discovered was that the United States Department of Agriculture (USDA) data on broadband access was not only inaccurate but wildly so. In collecting these data, the USDA, the Federal Communications Commission (FCC), and the U.S. Census Bureau used a methodology that examined whether or not broadband services were available in a census district. So, if at least a handful of households actually had the option to subscribe to Internet services, the census district was counted as having broadband access.

The problem, here, is that…that’s not how any of that works. The real-world experience of rural Americans living in many of those census districts was that only a handful of households had access to any type of Internet service. They did not take into account whether or not the services qualified under the federal definition of “broadband” or “high-speed Internet,” if those services were available to a majority of the district, if those services were reliable, if those services were affordable, and if those services provided speeds that could support what telehealth and virtual schooling required.

This created an interesting but wholly inconvenient innovation, particularly in states like West Virginia, Virginia, and Maryland, where school districts would deploy school buses fitted with Wi-Fi services and Internet hotspots that would allow parents and students to drive to set locations where they would then sit in their vehicles (or outside, weather permitting) to attend school virtually. This innovative approach helped many rural students attend school when they might otherwise never have been able to do so.

This program was ended in September of 2025 by the Trump Administration’s FCC (Gray, 2025).

So…why the divergence into rural broadband access?

Because “access to the Internet” has been added as an SDOH, in no small part because of the COVID-19 pandemic (Benda et al., 2020; Early & Hernandez, 2021; Agency for Healthcare Research and Quality, 2021). So important was access to high-speed Internet that the federal government created the Affordable Connectivity Program that provided a government subsidy to cover $50 of the monthly cost of Internet services (FCC, 2025).

Republicans in Congress also chose to end this program (Collins, 2024).

Without access to the Internet, rural patients are still required to travel to reach locations that can support telehealth visits, which puts them back where they started: potentially unable to reach affordable healthcare services due to transportation or geographic barriers.

Beyond Internet connectivity, rural areas tend to be less “walkable,” meaning that a vehicle is basically required in order to reach the goods and services that one needs in modern society to participate and thrive. This means that almost every aspect of life, including buying groceries, paying bills, clothing your family, going to school, going to the gym, going to the doctor, and/or going to work, requires driving or riding to that location.

One of the reasons why residents of urban areas tend to have higher levels of physical activity is that they are able to walk or use public transportation to reach many or most of the places they need to go. Meanwhile, rural residents can spend hours in a car traveling to and from the places they need to go, only to engage in limited physical activity when they arrive.

“Well, they should just walk more!”

Have you ever tried walking around your doctor’s waiting room to get in your steps?

Yeah.

It's awkward.

But what studies like Liu et al.’s show is that there are some solutions, if only we have the political will to actively fund socioeconomic development in rural America. This, unfortunately, always seems to be at the bottom of the “To Do” list for federal legislators, despite legislators from rural states having an outsized and disproportionate impact on federal legislation. One would think that, for all of the Mike Johnsons, John Thunes, Mitch McConnells, and Marjorie Taylor Greenes, improving socioeconomic outcomes in rural America would be higher on that list.

But, like with everything in rural America…it seems we’ll just have to wait.