Rural Americans are statistically older, heavier, poorer, and sicker than their urban counterparts. They’re also now more likely to die from COVID-19.

The initial stages of the pandemic impacted urban areas far more heavily than rural ones. But, as I wrote in The Hill in April 2020, it was inevitable that COVID would move beyond urban enclaves and into rural areas.  The data now supports that hypothesis. As of mid-September, metropolitan areas saw a seven-day average death rate of 0.41 while rural communities averaged a death rate of 0.85. This tracked with data from the Rural Policy Research Institute (RUPRI) that tracked death rates over the course of the pandemic. From June to September, the seven-day moving average for cases in urban and rural areas largely held the same until August, where it gradually diverged. In September, the seven-day moving average in rural areas was 66.8 confirmed cases per 100,000 while in urban areas it was around 43.3 cases per 100,000.

Low vaccination rates, limited resources, closing hospitals

Currently, the incidence rates of COVID are higher in rural America than in urban America. Researchers believe COVID incidence rates were 54 percent higher in rural areas than elsewhere for September. In 39 states, rural counties had higher rates of COVID than their urban counterparts. This was due to comparatively lower vaccination rates than in urban areas.

Roughly 41 percent of rural America was vaccinated in September, compared to 53 percent of urban America. Initially, limited supplies and low access made vaccines hard to find. Now, vaccine hesitancy seems to be the main culprit (even as I advocated for a more grassroots approach to combating vaccine hesitancy in the USA Today in March 2021).

Furthermore, the overload of hospitalized COVID patients underlined a key deficiency in rural health infrastructure: the ability to transport patients out of rural hospitals into more advanced regional or urban medical centers. As written about in the past, a major reason for this is the rapid rate of rural hospital closures over the past two decades. Since 2005, 181 rural hospitals have closed – including 39 since 2019. Often, these hospitals served as major employers and community anchors for these communities.

Since 2005, 181 rural hospitals have closed, including 39 since 2019. When rural hospitals close, patients must travel long distances to find hospital care. Likewise, patients in need of complicated procedures must be life-flighted miles to more advanced regional and urban medical centers.

While it’s easy for many white-collar urbanites (and suburbanites) to look at rural America as backward, uneducated, and hapless, it’s important to understand the broader context of how these areas were affected by demographic, economic, and societal trends in recent history.

The American population urbanized and left rural America behind

From 1953 to 2003, America’s rural population declined from 36 percent of the population to 21 percent. What’s more, U.S. Census data showed that over the last two decades, that massive population declines occurred in rural areas while urban and suburban areas grew by double digits. By 2050, less than 13 percent of Americans are projected to live in rural areas.

The effects of these changes cannot be understated.

The decline of small farms and rural manufacturing reduced employment opportunities for educated youth, driving many to leave (and never return). In the decade since the Great Recession, four-fifths of rural counties have fewer businesses today than in 2008.  This change has many downstream effects. When businesses leave, employees often follow suit. The efflux of population and business ultimately decreases tax revenues for local governments. As tax revenues decrease, cities lose funding for public services and make communities less attractive for new residents. Most importantly, fewer opportunities exist for local kids (and families) who want to stay.

From 1953 to 2003, America’s rural population declined from 36 percent of the population to 21 percent. Recent U.S. Census data underscores this trend. Concurrent with this population exodus, rural America’s businesses, broadband, and hospitals fell behind that of their urban and suburban counterparts. (Source: U.S. Census)

Interestingly, rural America struggled to recover from the Great Recession of 2008-09 at the same rate as urban America. In 2010, urban and rural America shared a similar loss of employment following the Recession – around -5.4 percent and -5.5 percent from 2007, respectively. While this unemployment number only differed by one-tenth of a percent in 2010, by 2017 those numbers were far more divergent. In 2017, urban areas saw a 7 percent increase from their 2007 baseline employment, whereas non-metro, rural areas saw a 2.0 percent decrease. This nine-point employment differential following the Great Recession reflects the divergent trajectories of the two American regions.

From 2007 to 2010, urban and rural America shared a similar loss of employment following the Great Recession: 5.4 percent and 5.5 percent, respectively. Over the succeeding decade, urban and rural unemployment rates diverged significantly. (Source: U.S. Department of Agriculture)

Fixing rural health care means improving economic opportunity for all aspects of rural America

Rural America will always follow its urban peers in economics, infrastructure, and health care. This is the way it has always been, and likely, the way it will continue to be. But the gap in resources and opportunities between the two areas is wider than at any point in modern memory. Over the next year, we will explore ways to revitalize and reposition rural America for the 21st century.