Expert Commentary

Rural Americans struggle with health costs, lack of high-speed internet access

Paying for medical, housing or food bills is a challenge for 40% of rural American adults, according to the results of a new nationally representative survey.

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About one-quarter of adults living in rural parts of the U.S. were not able to get health care when they needed it during the past few years, despite having health insurance, according to new findings from a national survey made public on Tuesday.

The survey is the second in a series that aims to capture the experience of life in rural America, or areas of the country that fall outside a Metropolitan Statistical Area (MSA). The effort is a collaboration of the Harvard T.H. Chan School of Public Health, NPR and the Robert Wood Johnson Foundation. (Robert Wood Johnson has provided funding for Journalist’s Resource.)

The previous report, released in October 2018, found that rural Americans were preoccupied by economic issues and the opioid epidemic. This recent update, based on responses from a nationally representative sample of 1,405 people aged 18 or older, delves deeper into the economic challenges facing rural Americans, as well as specifics of other aspects of the rural experience, such as health and social issues.

The telephone survey was conducted between Jan. 31, 2019 and March 2, 2019.

Here are some of the key findings:


  • Paying for medical, housing or food bills was a challenge for 40% of rural adults. The most problematic expenses were medical and dental bills, with 32% of respondents saying they or their families had problems paying them. Housing payments were second most common, with 19% reporting issues. Food bills posed challenges to 17% of the surveyed population.
  • Nearly half of those surveyed (49%) said they would have a problem paying an unexpected $1,000 expense in full immediately. Native Americans, black Americans and individuals of all races and ethnicities without college degrees were more likely to have trouble paying off such an expense.
  • Uninsured adults were more likely than insured adults to have trouble accessing necessary health care — 42% said they didn’t receive care when they needed it.
  • The most common reason why rural Americans didn’t get necessary care was cost — 45% said they couldn’t afford care when they needed it. Nearly a quarter — 23% — said that health care was too far away or too difficult to access. Almost as many — 22% — said they couldn’t schedule an appointment during a time that worked for them, and 19% said they couldn’t find a doctor who accepted their health insurance.
  • Almost 1 in 10 rural adults — 8% — reported recent hospital closures in their communities. Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, told JR that while this statistic might run counter to the “drumbeat of news about rural hospitals closing,” she didn’t find it surprising, given that the number of rural hospitals that have closed since January 2010 figures around 100. However, she noted that a greater share of respondents might unknowingly be living near a hospital in financial distress or under the threat of closure.
  • Nearly one-quarter of rural adults (24%) have used telehealth — accessing health care through phone, email, text messaging, chat, a mobile app, or live video — over the past few years. The majority of these people were satisfied with their experience. And 69% said they chose telehealth because it was the most convenient way to get a diagnosis or treatment. Other reasons cited for using telehealth: respondents couldn’t see their usual doctor in person (30%), and/or they found it too hard to travel to the doctor (26%).


  • Many rural Americans lack reliable access to high-speed internet — 21% say access is a problem.
  • The vast majority of rural Americans (90%) think it is very or somewhat important to have a car or other vehicle to do what they need to do on a daily basis.
  • Though most rural Americans say they have people nearby who they can rely on for help or support, 18% report always or often feeling either isolated or lonely. “The research has shown that [people who experience] social isolation and loneliness — but particularly social isolation — have an increased risk for cardiovascular disease, for diabetes and for mental health issues,” said Maryjoan D. Ladden, a senior program officer at the Robert Wood Johnson Foundation whose work focuses on loneliness and social isolation. “Being socially isolated and lonely is as much a risk to your health as obesity and some of the other lifestyle factors that we think about.”
  • Groups that were more likely to report feeling isolated or lonely include: rural adults with disabilities, rural adults in households earning less than $25,000 per year and rural Americans between the ages of 18 and 29. “My sense about rural is that those that are older grew up in these types of settings and are used to it,” Ladden added. “But the younger age group — I think because of social media and other things — are perhaps more aware of the things that they are missing because they’re in a rural area.”


  • Overall, one-third of rural adults said that homelessness is a problem for their community. By region, adults in the Pacific West were most likely to say homelessness is a problem — 75% cited it as an issue. Respondents in the rural Midwest represented the low end of the spectrum — 26% said homelessness is a problem in their community.
  • Other housing issues experienced by rural Americans include: pests, bugs, and wild animals; problems with phone service; unsafe drinking water; mold or other environmental issues; inadequate heating or cooling; electrical problems; and issues with the sewage system. In total, 22% of those surveyed were concerned about their housing conditions affecting the health or safety of their families. These concerns were more common among rural Americans living in mobile homes than those living in houses or apartments.
  • Rural Americans were more likely to describe their community as safe (88%) compared with adults nationally (79%).


  • A majority of respondents (73%) felt their overall quality of life was excellent or good. However, those without college degrees were more likely to report their quality of life as fair or poor (29%), compared with those who had college degrees (16%). Meanwhile, 45% of black adults and 39% of Native American adults living in rural areas rated their overall quality of life as fair or poor, as did 41% of all rural Americans earning less than $25,000 per year and 43% of all rural Americans with disabilities.

For more on rural health, check out our 3 tips for reporting on the topic. We also have plenty of research and tip sheets about rural America on our “rural” tag page.

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