The Rural Crisis

By Frank F Islam & Ed Crego, October 10, 2023 (Image credits: Tom de Boor, Adobe, et al)

The urban-rural divide has become a popular catch phrase in this 21st century to describe the increasing distance politically between Democratic supporters, who reside primarily in urban areas, and Republican supporters, who reside primarily in rural areas.

When it comes to the respective conditions in both of these areas today, however, there is no divide. There is a significant amount of un- or under-addressed physical and human needs in both.

We focused on the needs in urban areas in our blog preceding this one. In this blog, we focus on the needs in rural areas.

The Economic Research Service of the U.S. Department of Agriculture states in its 2022 Edition of Rural America at a Glance, “The population in rural (nonmetro) counties stood at 46.1 million in July 2021, with 14 percent of the U.S. population residing in 72 percent of the Nation’s land area.”

The Nature of the Rural Crisis

While the label “crisis” has been employed frequently in referring to problems in urban areas, and has garnered most of the public and political attention over the past several decades, the problems in these rural (non-metro) areas are multi-dimensional and crisis-like as well.

In a report updated in January 2020 using data from 2019, the National Conference of State Legislatures (NCSL) observed:

Rural communities face challenges related to demographic changes, workforce development, capital access, infrastructure, health, land use, and environment and community preservation. Compared to their urban counterparts, rural areas have less internet access, fewer educational institutions, see more hospitals close, and experience less economic growth.

Those are just some of the challenges confronting rural America and Americans today. There are numerous others. Among the most significant current challenges are: health care; mental health; and housing and homelessness.

Health Care

The health care situation for much of rural America is a dire one. The Centers for Disease Control and Prevention, in a May 9, 2023 update of About Rural Health, reports:

Rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their urban counterparts. Unintentional injury deaths are approximately 50 percent higher in rural areas than in urban areas, partly due to greater risk of death from motor vehicle crashes and opioid overdoses. In general, residents of rural areas in the United States tend to be older and sicker than their urban counterparts.

About Rural Health goes on to note that contributing factors to these “poor health outcomes” include: higher rates of cigarette smoking, high blood pressure, and obesity, less leisure-time physical activity, and lower seatbelt use than their urban counterparts. In addition, rural residents also have higher rates of poverty, are less likely to have health insurance, and have less access to health care.

In terms of access to health care in the rural areas consider the following data from a March 18 ABC News article on the “rural health care crisis,” written by Peter Charalambous:

  • At least 136 rural hospitals and health systems closed between 2010 and 2021, and over 40% of rural hospitals operate with negative profit margins.
  • In 2020, 47% of rural community hospitals did not provide obstetric services, with 89 obstetric units closing between 2015 and 2019.
  • Rural areas comprise about two-thirds of the primary care health professional shortage areas nationwide, even though only 20% of Americans live in rural areas.
  • Projections indicate that the United States will likely suffer a shortage of between 17,800 and 48,000 PCPs by 2034.

Add to this lack of access problem, the fact that, as Nada Hassanein reports in a June 26 USA Today article:

Nearly 4.5 million people across the U.S. live in an “ambulance desert” — 25 minutes or more from an ambulance station — and more than half of those are residents of rural counties, according to a new national study by the Maine Rural Health Research Center and the Rural Health Research Centers.

Mental Health

The mental health situation in rural America rivals the health care situation in its direness.

The scope and nature of the mental health challenges are highlighted in a piece by Jeff Winton for The National Alliance on Mental Illness, published on November 17, 2022. According to that piece, they include the following:

  • Rural Americans experience higher depression and suicide rates than people who live in urban areas. The suicide rates in rural areas were 18.3 to 20.5 per 100,000 residents compared to 10.9 per 100,000 in urban areas.
  • The COVID-19 pandemic had a major impact on mental health in rural America, with 53% of rural adults and 71% of younger rural adults reporting the pandemic had affected their mental health.
  • 37 million rural residents live in mental health professional shortage areas.
  • In rural counties, 65% lack a psychiatrist; 81% a psychiatric nurse practitioner; and 47% a psychologist.

Housing and Homelessness

The lack of affordable housing and homes for those in poverty are additional considerable challenges for those living in rural America.

The Daily Yonder, a source for news devoted to rural America, in a March article on “rural America’s hidden housing crisis,” succinctly comments:

Nationwide, homelessness rose less than a half percent from 2020 to 2022 but almost 6% in rural communities. The reasons are many and varied.

A primary factor is, of course, the cost of housing, said Lance George, director of research and information at the Housing Assistance Councilin Washington, D.C. Wages are often stagnant, he said, and housing costs keep rising.

Compounding the problem is the fact that because large-scale development is rare in rural communities, construction costs are often higher and there’s therefore less incentive for private investment.

Community Solutions, in an August 3 post by Chan Kemper, adds the following detail to this narrative:

  • From 2021 to 2022, rural Continuums of Care saw a 27% increase in homelessness.
  • According to the National Low-Income Housing Coalition, nearly $5.6 billion is needed over the next 20 years to preserve the more than 470,000 rental homes within USDA’s portfolio for current and future residents.
  • USDA estimates that rural communities will lose nearly 1,800 rental homes annually due to maturing mortgages between 2016 and 2027, more than 16,000 rental homes annually between 2028 and 2032, and 22,000 homes annually in the following years.

Recommendations for Addressing the Rural Crisis

While the rural crisis has been less visible nationally than the urban crisis, there has been no dearth of recommendations for addressing it. The recommendations range from ones directed at confronting the overarching reasons for the crisis to those directed at specific challenges.

Tony Pipa is a senior fellow in the Center for Sustainable Development at the Brookings Institution who launched and leads The Reimagining Rural America Initiative. Pipa published a guest essay for the New York Times on December 27, 2022, in which he says:

Despite widespread acknowledgment since 2008 that rural places have generally been left behind, our nation still lacks a coherent federal rural policy.

Almost a century ago, federal policy like the Rural Electrification Act, Title V of the Housing Act and other national-scale development programs helped bring rural America into the modern era, and its contributions helped make the American economy the envy of the world. But today’s federal programs were built for a different era. We need a renaissance of rural policy to enable a renaissance of rural America.

In his essay, Pipa identifies several current policy deficiencies and federal bureaucratic obstacles and entanglements and provides recommendations to correct or overcome them such as making it easier to access the funds available through the Infrastructure Jobs Act, the CHIPs and Science Act, and the Inflation Reduction Act. (Pipa provides more background and rationale for his recommendations in his July 24, 2023, Brookings commentary)

While Pipa focuses on federal policy in his Times article, the National Conference of State Legislatures focuses on state policy. According to the NCSL report cited earlier in our blog, “Legislatures in ten states have initiated rural commissions and committees, dedicated to improving the rural areas of their state.” The Report also highlights states with rural legislation; broadband legislation; economic development legislation; and federal land legislation. And it also identifies a variety of resources to be used in dealing with the key challenges in rural communities.

In terms of the specific challenges discussed in this blog, The Centers for Disease Control and Prevention puts forward recommendations for health care improvement in rural areas. The National Alliance on Mental Illness presents recommendations to address mental health problems. And Community Solutions summarizes recommendations for dealing with housing and homelessness issues.

Reflecting on the Rural Crisis

Sum the recommendations up and it becomes apparent that the problem is not a lack of analysis, answers, or approaches to be employed in response to the rural crisis but a failure to develop and move forward on a national agenda to ameliorate or resolve the crisis.

This failure exists for many reasons, but a principal one is undoubtedly the fact that there is a significant political divide in this polarized country and in the halls of the U.S. Congress. That divide over the past decade has made it increasingly difficult to reach a joint agreement on essential federal legislation.

In 2013, we published our book, Working the Pivot Points: To Make America Work Again. We opened the chapter in that book titled, “Congressional Dysfunction: Beltway Blues” as follows;

The 112th Congress which was in office from January 3, 2011 to January 3, 2013 may have been the worst Congress in history.

That’s hard to determine objectively. It is easy to determine, however, that the 112th was the least productive Congress ever.

The 112th was also held in exceptionally low regard by the American citizens.

At that time, we hoped and expected that things would improve in Congress as a pivot point and in Congress’ ability to work on pivot points in the future. Sadly, over the past ten years, they have not.

Some time ago, Republicans and Democrats used to “work across the aisle” by uniting to reach an agreement on mutually acceptable pieces of legislation. Over the past ten years, in general, this has not been the case.

Instead, there has been little common ground to work or walk on. Collaboration and compromise have become dirty words and antiquated practices.

This was definitely the case during the Trump presidential years. Thankfully, under the Biden presidency, there has been some positive progress. The Inflation Reduction Act, the Infrastructure Act, and the CHIPs and Science Act, which passed with bipartisan support, all included provisions that are beneficial to rural areas and communities.

In conclusion, it is not just Congress that will determine whether there will be initiatives of sufficient scope and scale nationally to respond effectively to the rural crisis. It will be impacted by committed and responsible citizens living in both rural and urban areas who recognize that the rural crisis presents challenges not only for those living in the country but for the country itself.

Those citizens will see this as an opportunity to join together by putting the country first rather than promoting an ideological or political divide. They will support elected officials who do the same. By so doing, they will ensure that our country’s roads will be built to take everyone home safely regardless of their location.