Rural Health Resilience: A Four-Part Series On Healing The Other America

Forbes

15-07-2025

Preface: Why Rural Health Demands a National Conversation
This essay is the first in a four-part series I'm calling Rural Health Resilience—a look at the state of rural health in America through the eyes of a surgeon, policymaker, and entrepreneur. Over the course of my life, I've cared for patients referred from rural hospitals and doctors as a surgical intern; I've treated them in VA hospitals and academic medical centers as a heart and lung specialist, and represented their interests in Washington as a senator from Tennessee. I've helped design companies—like Aspire Health, Main Street Health, and Monogram Health—that now serve hundreds of thousands of rural Americans in their homes and communities. And I've personally operated as a surgeon in remote clinics across sub-Saharan Africa, where geography often determines survival. I'm not an expert in rural care but I try to be a keen observer.
What I've learned is that rural America is too often overlooked. But its health is inextricably tied to the health of the nation. No longer can we expect financial, organizational, and delivery models designed for urban areas to work in rural communities. They don't. We must meet the needs of rural populations with a new, more tailored approach. I'll share some ideas as potential solutions over the course of this series.
This series will explore four pillars of the rural health landscape:
1. The Rural Health Crisis: How We Got Here—and Why It Affects Us All (this first essay)
2. Closing the Distance: Fixing Access to Care in Rural America
3. What Counts: How Technology Can Transform Rural Health
4. A Healthy Return: How Investing in Rural Care Is Good for America
BROWNSVILLE, TN - The demise of Haywood Park Community Hospital added Brownsville, Tennessee to the ... More emergency services plight being endured in many rural communities across America. Photo by Michael S. Williamson.
The Rural Health Crisis: How We Got Here—and Why It Affects Us All
A Crisis in Plain Sight
I first began thinking seriously about the vulnerabilities of rural health not from a policy paper, but from a patient. He was a 52-year-old farmer from western Tennessee—stoic, salt-of-the-earth, the kind of man who only came to the doctor when he could no longer walk up the stairs of his tractor. By the time he made it to me, a heart specialist, he was in advanced heart failure. His local hospital had closed. The nearest cardiologist was two counties away. And the many barriers to reach specialty care had cost him precious time.
This man's story is not unique. In fact, it's painfully common.
Rural America today is facing a slow-moving health crisis that affects nearly 60 million people—roughly one in five Americans. The definition of 'rural' varies slightly by government agency but broadly includes non-metropolitan counties characterized by lower population density, distance from urban centers, and limited commuting access. These communities span the country, from Appalachia to the Mississippi Delta to the high plains of Montana—and together they form the backbone of our country's food, energy, and cultural identity. And, yes, they include even populous coastal states like California, New York and Florida which contain significant rural regions—places where access, infrastructure, and outcomes mirror those of what are thought of more traditionally as rural states.
These same communities are facing disproportionately high rates of chronic disease, mental illness, maternal mortality, and premature death. The phrase 'rural mortality penalty' is real. According to Dr. Shannon Monnat, a rural demographer at Syracuse University, 'The rural U.S. is sick, poor, and losing population. And the health and longevity gap between rural and urban America is growing wider every year.'¹
By the Numbers: Geography as Destiny
The data are stark:
These are more than numbers. They are lives cut short. Families left behind. Communities depleted.
The Health Gaps We Don't See
Rural health disparities aren't just about the availability of clinics or emergency rooms. They're deeply tied to social determinants of health, such as housing, transportation, education, food access, income inequality, and broadband connectivity.
As Dr. Carrie Henning-Smith of the University of Minnesota notes, 'The biggest drivers of rural health inequities are not medical. They are structural.'² In rural America, patients are more likely to live in substandard housing, lack access to reliable transportation, and face chronic food insecurity. These social risks compound clinical ones. Lasting solutions must include attention to each of these.
Put simply: many rural Americans aren't dying because they can't get to a doctor. They're dying because of what happens long before they need one.
Loneliness and social isolation are significant public health concerns in the US, with rural areas ... More often facing unique challenges that exacerbate these issues. Rural residents may experience higher rates of loneliness due to factors like social isolation, poorer health, and socioeconomic disadvantages. These factors can contribute to increased risks of depression, suicide, and other health problems.
Aging, Isolation, and Infrastructure Breakdown
Rural America is aging rapidly. Nearly one in five rural Americans is over 65. Many are aging in place, even as younger generations move away. That means more and frequently older people with complex needs, and fewer providers or caregivers to meet them.
These older adults are often managing multiple chronic illnesses without access to home-based care, nearby pharmacies, or geriatric specialists. As Dr. Tim Slack of Louisiana State University puts it: 'What we're seeing is a slow erosion of the systems that support health—economic, medical, and civic.'³
Meanwhile, in a post-COVID world, we've heralded telehealth as a powerful solution. And it can be, if patients have broadband. But millions still don't. Whether due to cost, geography, or digital literacy, virtual care remains inaccessible to many of the people who need it most.
Real Stories, Real Stakes
I've seen this reality firsthand. At Monogram Health, we care for patients with advanced kidney disease who can't safely reach dialysis centers. At Aspire Health, which focuses on palliative care, we treated rural seniors with complex, life-limiting illness, frequently homebound, often alone, disconnected from coordinated care. And through Main Street Health, we've built a primary care model that deploys trusted, local 'health navigators' in rural communities in 22 states to meet patients where they are, geographically and clinically.
These aren't pilot projects. They each started as innovative ideas, each thoughtfully organized with rural needs in mind. Now they are proven and operating at scale. They demonstrate that rural care can work. But only if we design it intentionally and sustainably, listening to the local needs of the communities and aggressively engaging them in the solutions.
Not a Monolith, But a Shared Challenge
Rural America is diverse — racially, economically, and culturally. The needs of an Appalachian coal town differ from those of a tribal health center in South Dakota or a farming community in California's Central Valley. But core vulnerabilities are shared.
As Monnat reminds us, 'We often treat rural as a category of deficiency. But the truth is that rural communities have enormous assets—tight-knit networks, cultural resilience, and deep place-based knowledge. They just need systems that work with them, not around them.'⁴
Truck on gravel road in northern Minnesota.
A Call to See—and Then to Act
The rural health crisis is more than a sidebar to the national conversation. It is the national conversation. If we ignore the progressive decline in rural health, we risk losing entire communities. Economically, we lose labor. Socially, we lose trust. Politically, we deepen divides.
But I believe rural health is also one of the greatest opportunities we have to make meaningful progress in American healthcare. That's what this series is all about. The data are in. The models exist. And the roadmaps are clear. Smart rural health solutions can accelerate care for all America; we will explore this more in essay three where we focus on technology.
What's Next
In the next essay, we will look at the specific barriers keeping rural Americans from accessing care and the innovations helping bridge the divide. From workforce shortages and transportation challenges to mobile health units and broadband expansion, we'll examine what's broken—and what's working.
And a final thought: if we can't get healthcare right for 60 million Americans who feed us, fuel us, and form the fabric of this country—who are we getting it right for?Footnotes