Tracing Rural America’s ‘Mortality Penalty’

Beginning in 1989, rural Americans began dying at a higher rate than Americans living in cities. Nobody knows why.

Share This:

The difference between the death rates in rural and urban America has been increasing since 1990. Mortality rates have declined in both the cities and the countryside, but since 1990 urban death rates have improved at twice the rate of rural. (See chart above.)

As a consequence of the changing rates of mortality, hundreds of thousands of rural residents have died since 1990 who would have been expected to live had the gap not appeared, according to researchers who first discovered this shift in rural health last year.

Before 1990, the mortality rate for both rural and urban communities had been about the same — and both were decreasing. Death rates in rural and urban America have continued to decrease since 1990, but the rate of decline has been much faster in urban areas. 

If the gap between rural and urban mortality rates had remained constant, there would have been more than 389,000 fewer deaths in rural communities between 1990 and 2004. Researchers call this the “nonmetropolitan mortality penalty.”

The high rural mortality rates is another example of a health penalty paid by rural residents. Last year, researchers at Harvard University found that life expectancy for women living in nearly 1,000 mostly rural counties had declined from 1983 to 1999. 

And last week, another group of researchers reported that the rate of suicides in rural counties jumped some time in the 1980s or 1990s. In the 1970s, rural and urban places had similar rates of suicide and attempted suicide. By the late 1990s, rates of suicide were 54% higher in rural areas than in U.S. cities. 

In 1989, rural communities, on average, had six more deaths for each 100,000 residents than urban communities. By 2005, however, there were 82 more deaths for each 100,000 rural residents than for a similar number of people living in urban areas.

“These excess deaths are equivalent to approximately 9% of the total mortality in the nonmetropolitan (rural) United States,” according to Arthur Cosby and other researchers writing in the August 2008 issue American Journal of Public Health. Cosby is a sociologist at Mississippi State University.

The gap between rural and urban mortality rates has been accelerating. And a new report from the Economic Research Service finds that the death gap between rural and urban America continued into 2005. 

The difference in death rates from one region to another is larger than the gap between rural and urban. the highest death rates are in the South and Appalachia. Click here for a larger version of the map.

Nobody has determined why the difference in mortality rates is widening. “A possible explanation for the emergence of the nonmetropolitan mortality penalty is based on the observation that access to health care is the most pervasive health disparity in the nonmetropolitan United States,” Cosby wrote in 2008. “If healthcare is becoming significantly more effective in prolonging life, then limited access to healthcare is becoming profoundly harmful to the nonmetropolitan US population, hence, the nonmetropolitan mortality penalty.”

The ERS (the research division of the Department of Agriculture) found that since 1990, urban mortality rates have improved at twice the rate of rural mortality rates. “However, within the metro and nonmetro county groups, rates vary significantly across regions associated in part with differences in patterns of persistent poverty, race, and ethnicity of the populations,” the federal researchers wrote.

There are greater differences in mortality rates across rural regions than between urban and rural counties. 

Rural counties in the West have the lowest mortality rates while those in the South have the highest. (See map.)

The gaps between metro and nonmetro counties are also greatest in the South. In the Midwest, for example, there is no gap between metro and nonmetro counties.

The death rates in the Farm Belt are low. “The high mortality rate clusters are in the South, including the Mississippi River Delta, the Black Belt of the southern coastal plain from Virginia through Alabama, and Appalachia,” the ERS reported. “Factors associated with higher mortality across the clusters include high persistent-poverty rates, high shares of Black or Appalachian population and low rates of high school graduation.”

Cosby and his group of researchers urged in 2008 that the “nonmetropolitan mortality penalty” be the subject of a major investigation.

“Are causes underlying the growing nonmetropolitan mortality penalty subject to intervention?” they asked. “What are the health policy implications of a growing nonmetropolitan mortality penalty? We suggest that an ambitious research agenda needs to be undertaken to meaningfully evaluate and utilize our preliminary finding of an emerging nonmetropolitan mortality penalty in the United States.”


News Briefs