Rural health disadvantages in the United States: Evidence from nationally representative data

A gap in mortality rates between rural and urban areas emerged in the late 1990s as rural residents began dying at a higher rate than their urban counterparts. This mortality gap has been widening ever since. The growing mortality gap is pronounced among prime working-age adults (ages 25-54), which has important implications for rural health, productivity, and economic development. Despite the heightened mortality rates in rural areas in recent decades, there is still a limited understanding of the health-related mechanisms fueling this worsening rural-urban mortality disparity. Using nationally representative data from the 1999-2000-2017-March 2020 cycles of the National Health and Nutrition Examination Survey, we combine individual-level data, including biomarkers, and place-based characteristics to create a comprehensive dataset spanning 20 years. In a descriptive analysis, we use linear regression models to estimate the magnitude of rural-urban gaps in health behaviors and outcomes-or mortality risk indicators-for the overall adult and prime working-age populations. We document a suite of rural health disadvantages, which may be informative for understanding the growing rural longevity gap. These disadvantages are often attenuated and no longer statistically significant after accounting for county-level characteristics. A complementary decomposition analysis indicates that county characteristics account for a larger share of the variation in health measures than rural-urban status. Our results can inform decision-makers aiming to improve rural health and economic outcomes and may spur further research using biomarker data alongside place-based characteristics.