Updated: Feb 24
Distance and Transportation
Rural populations are more likely to have to travel long distances to access healthcare services, particularly subspecialist services. This can be a significant burden in terms of travel time, cost, and time away from the workplace. In addition, the lack of reliable transportation is a barrier to care. In urban areas, public transit is generally an option for patients to get to medical appointments; however, these transportation services are often lacking in rural areas. Rural communities often have more elderly residents who have chronic conditions requiring multiple visits to outpatient healthcare facilities. This becomes challenging without available public or private transportation. RHIhub's Transportation to Support Rural Healthcare topic guide provides resources and information about transportation and related issues for rural communities.
Healthcare workforce shortages impact healthcare access in rural communities. One measure of healthcare access is having a regular source of care, which is dependent on having an adequate healthcare workforce. Some health services researchers argue that evaluating healthcare access by simply measuring provider availability is not an adequate measure to fully understand healthcare access. Measures of nonuse, such as counting rural residents who could not find an appropriate care provider, can help provide a fuller picture of whether a sufficient healthcare workforce is available to rural residents.
A shortage of healthcare professionals in rural areas of the U.S. can restrict access to healthcare by limiting the supply of available services. As of March 2021, 61.47% of Primary Care Health Professional Shortage Areas (HPSAs) were located in rural areas.
Health Insurance Coverage
Individuals without health insurance have less access to healthcare services. A U.S. Census Bureau report, Health Insurance Coverage in the United States, 2018, found that 9.1% of the population living outside metropolitan statistical areas (MSAs) did not have any type of health insurance in 2018, compared to 8.4% of the population within MSAs. According to Infants Without Health Insurance: Racial/Ethnic and Rural/Urban Disparities in Infant Households' Insurance Coverage, 2011-2015 data revealed that 19.9% of infants in rural households did not have health insurance, which was greater than the 16.8% of infants in urban households who lacked insurance.
The June 2016 issue brief from the Office of the Assistant Secretary for Planning and Evaluation, Impact of the Affordable Care Act Coverage Expansion on Rural and Urban Populations, found that 43.4% of uninsured rural residents reported not having a usual source of care, which was less than the 52.6% of uninsured urban residents reporting not having a usual source of care. The brief reports that 26.5% of uninsured rural residents delayed receiving healthcare in the past year due to cost. The Affordable Care Act and Insurance Coverage in Rural Areas, a 2014 Kaiser Family Foundation issue brief, points out that uninsured rural residents face greater difficulty accessing care due to the limited supply of rural healthcare providers who offer low-cost or charity healthcare, when compared to their urban counterparts.
Health insurance affordability is a concern for rural areas. A RUPRI Center for Rural Health Policy Analysis policy brief, Health Insurance Marketplaces: Issuer Participation and Premium Trends in Rural Places, 2018, evaluated changes in average health insurance marketplace (HIM) plan premiums from 2014 to 2018. Average premiums were higher in rural counties than in urban counties. In addition, rural counties were more likely to have only one insurance issuer participating in the HIM.
While the use of telehealth services was already becoming more popular and widespread at the beginning of 2020, measures implemented in response to the COVID-19 pandemic accelerated this growth. Unfortunately, many areas lack access to broadband internet and experience slow internet speeds, both of which are barriers to accessing telehealth services. Compared to their urban counterparts, rural individuals are nearly two times more likely to lack broadband access. A Peterson Center on Healthcare and Kaiser Family Foundation report, How Might Internet Connectivity Affect Health Care Access?, stated that 7% of people in metropolitan areas did not have access to internet at home in 2019, while 13% of people in nonmetropolitan areas lacked access. To learn about additional challenges for rural telehealth use, see What are the challenges related to telehealth services in rural communities? on RHIhub's Telehealth Use in Rural Healthcare topic guide.
Poor Health Literacy
Health literacy can also be a barrier to accessing healthcare. Health literacy impacts a patient's ability to understand health information and instructions from their healthcare providers. This can be especially concerning in rural communities, where lower educational levels and higher incidence of poverty often impact residents. Low health literacy can make residents reluctant to seek healthcare due to fear or frustration related to communicating with a healthcare professional. Additionally, navigating the healthcare system can be difficult without health literacy skills. To learn more about low health literacy in rural America, see What are the roles of literacy, health literacy, and educational attainment in the health of rural residents? on RHIhub's Social Determinants of Health for Rural People topic guide. The Rural Monitor's two-part series on rural health literacy, Understanding Skills and Demands is Key to Improvement and Who's Delivering Health Information?, explores connections between health and health literacy and how health information is being delivered to rural populations.
Social Stigma and Privacy Issues
In rural areas, because there is little anonymity, social stigma and privacy concerns are more likely to act as barriers to healthcare access. Rural residents can have concerns about seeking care for mental health, substance abuse, sexual health, pregnancy, or even common chronic illnesses due to unease or privacy concerns. Patients' feelings may be caused by personal relationships with their healthcare provider or others working in the healthcare facility. Additionally, patients can feel fear or concerns about other residents, who are often friends, family members, or co-workers, who may notice them utilizing services for health conditions that are typically not openly discussed, such as counseling or HIV testing services. Co-location or the integration of behavioral health services with primary care healthcare services in the same building can help ease patient concerns. Understanding Rural Communities, a 2018 podcast from the Hogg Foundation for Mental Health, features an interview with Dennis Mohatt, the Vice President for Behavioral Health at the Western Interstate Commission for Higher Education (WICHE), discussing rural health and the stigma surrounding mental healthcare in rural communities.