Moonshot, Upshot, Hot Spot, Bullshot
By Daniel Derksen, MD, Director at University of Arizona Center for Rural Health
Photography by workinjuryaz.com, Graphic by Paul Akmajian, University of Arizona Center for Rural Health
One in five Americans lives in a rural area. Yet it’s been 25 years since the U.S. invested in its rural health infrastructure through Hill Burton funding (1947-1997) based on community need. While 18-20% of the nation’s population lives in a rural area, just 10% of primary care physicians and 7% of specialist physicians reside there.
The Great Society Programs of the 1960s intended to address the 25% of Americans living below the Federal Poverty Level, and even higher (33% below FPL) in rural areas, and included creating a Job Corps, Head Start, Medicare, Medicaid, and other programs to expand affordable health care, education, and housing. Over that decade rural poverty dropped to 17.9%.
Investments in individual health insurance coverage started with amendments to the Social Security Act that created Medicare and Medicaid in 1965, added the Children’s Health Insurance Program in 1997, and in 2014 expanded Medicaid and subsidized private health insurance for 20 million Americans via the Affordable Care Act. These investments helped stabilize finances in rural hospitals and clinics. However, many community clinics, rural and critical access hospitals operate on thin margins without reserves to weather economic downturns.
In 2021, intractable rural versus urban socioeconomic and health disparities persist.
Rural counties are often defined simply as having a population of less than 50,000. There are more precise designations such as federal-state determinations for Health Professional Shortage Areas, Rural Urban Commuting Areas (RUCAs), and other sub classifications.
Rural America is demographically and economically diverse, suggesting that while some commonalities exist (rural populations tend to be older, have lower incomes, and higher rates of certain chronic diseases), policy and programmatic interventions should be customized to meet diverse rural community needs. While rural age adjusted death rates per 100,000 are improving for cancer, coronary heart disease and stroke – they are not improving as much as in metro areas. Rural death rates are worsening for COPD, diabetes, unintentional injury and suicide.
Of the 69 million Americans living in rural areas, 13 million are people of color, and 2 million are immigrants. Rural residents who are Black, Latinx/Hispanic and American Indian have social determinants that contribute to poorer health outcomes including higher rates of poverty, lower educational attainment, and less access to affordable housing and health insurance coverage and services.
FACTOR  RURAL METRO
Poverty Rate 16.1% 12.6%
Children (<5 yrs.) in poverty 25.0% 18.6%
Food Insecure Households 15.5% 12.5%
PCP per 100,000 Population 39 53
Population > age 65 18% 14%
Smoking Rate 19.1% 15.8%
Obesity Rate 31.5% 26.7%
The sixth largest state, Arizona’s 114,000 square miles is 55% federal and state government land, and 28% is owned by 22 federally recognized American Indian tribes. Arizona has 15 large counties, four of which share the 377-mile Arizona-Mexico border. Maricopa County (4.5 million) and Pima County (1.1 million) comprise over 75% of Arizona’s 7.3 million population.
In its 13 other counties, rural Arizonans have poorer health outcomes, higher uninsured rates, less access to health services, and alarming disparities in COVID-19 infection, hospitalization and death rates in American Indian, Latinx, African American, and elderly populations.
For death rates per 100,000 population, heart disease (rate of 134 in 2019), cancer (131.1), accidents (58.7), chronic lower respiratory disease (38.1), and Alzheimer’s disease (32.3) are usually the leading causes of death in Arizona.
COVID-19 became the leading cause of death in 2020-21, with a rate of 246 per 100,000 population. COVID-19 hit rural Arizona hard. Apache County, home to 75% of the American Indians in Arizona, had a death rate of 603, over three times the US mortality rate of 179. Yuma County, where 65% of the population is Hispanic/Latinx, had a death rate of 367, over twice the US mortality rate.
Painting rosy, utopian pictures of rural America can be as misleading and misdirected as conveying only rural challenges and disparities. A balanced, clear-eyed view of the rural health ecosystem – in the context of a community’s assets, cultural diversity, and challenges - can be enhanced by monitoring progress (vital signs) and engaging the community in thoughtful ways to improve the health and well-being of its population.
Contemporary approaches to eliminating rural disparities must go beyond myopic, constrained, commodity models of cost, quality and access as a zero-sum game, where improving one element comes at the expense of another and cannot simultaneously be improved without tradeoffs.
As detailed by Don Berwick, Tom Nolan, and John Whittington, the Triple Aim is a compelling vision of improving the patient experience of care, improving the health of a population, and reducing the per capita costs of care. In Arizona, key partners that form the strands of Arizona’s rural health safety net include county public health departments, the state’s Medicaid program (AHCCCS), state health department (ADHS), legislators, the governor’s office, private physicians, advocacy organizations, and clinicians and staff.
 National Academies of Sciences, Engineering, and Medicine 2021. Population
Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC:
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 Arizona. National Center for Health Statistics. Centers for Disease Control and Prevention, Atlanta. Accessed online on June 7, 2021. Available at https://www.cdc.gov/nchs/pressroom/states/arizona/az.htm#lcod
 Arizona COVID-19 Dashboard. Arizona Department of Health Services, Phoenix. Accessed online on June 7, 2021. Available at https://www.azdhs.gov/covid19/data/index.php
 H Levins. William Kissick and The Iron Triangle of Health Economics. University of Pennsylvania Leonard Davis Institute for Health Economics; 2013. Available at https://ldi.upenn.edu/news/william-kissick-and-iron-triangle-health-economics
 DM Berwick, TW Nolan, and J Whittington. The Triple Aim: Care, Health, and Cost. Health Affairs; Vol. 23, No. 3; May/June 2008. https://doi.org/10.1377/hlthaff.27.3.759