By Jazmin Orozco Rodriguez for KFF Health News.
Broadcast version by Alex Gonzalez for Arizona News Connection reporting for the KFF Health News-Public News Service Collaboration

In Matthew Roach’s two years as vital statistics manager for the Arizona Department of Health Services, and 10 years previously in its epidemiology program, he has witnessed a trend in mortality rates that has rural health experts worried.

As Roach tracked the health of Arizona residents, the gap between mortality rates of people living in rural areas and those of their urban peers was widening.

The health disparities between rural and urban Americans have long been documented, but a recent report from the Department of Agriculture’s Economic Research Service found the chasm has grown in recent decades. In their examination, USDA researchers found rural Americans from the ages of 25 to 54 die from natural causes, like chronic diseases and cancer, at wildly higher rates than the same age group living in urban areas. The analysis did not include external causes of death, such as suicide or accidental overdose.

The research analyzed Centers for Disease Control and Prevention death data from two three-year periods — 1999 through 2001 and 2017 through 2019. In 1999, the natural-cause mortality rate for people ages 25 to 54 in rural areas was only 6% higher than for city dwellers in the same age bracket. By 2019, the gap widened to 43%.

The researchers found the expanding gap was driven by rapid growth in the number of women living in rural places who succumb young to treatable or preventable diseases. In the most rural places, counties without an urban core population of 10,000 or more, women in this age group saw an 18% increase in natural-cause mortality rates during the study period, while their male peers experienced a 3% increase.

Within the prime working-age group, cancer and heart disease were the leading natural causes of death for both men and women in both rural and urban areas. Among women, the incidence of lung disease in remote parts of the nation grew the most when compared with rates in urban areas, followed by hepatitis. Pregnancy-related deaths also played a role, accounting for the highest rate of natural-cause mortality growth for women ages 25 to 54 in rural areas.

The negative trends for rural non-Hispanic American Indian and Alaska Native people were especially pronounced. The analysis shows Native Americans 25 to 54 years old had a 46% natural-cause mortality rate increase over those two decades. Native women had an even greater mortality rate jump, 55%, between the two studied time periods, while the rate for non-Hispanic White women went up 23%.

The rural-urban gap grew in all regions across the nation but was widest in the South.

The increased mortality rates are an indicator of worsening population health, the study authors noted, which can harm local economies and employment.

As access to and quality of health services in rural areas continue to erode, rural health experts said, the USDA findings should spur stronger policies focused on rural health.

Alan Morgan, CEO of the National Rural Health Association, said he found the report “shocking,” though, “unfortunately, not surprising.”

The disparity warrants greater attention from state and national leaders, Morgan said.

The study does not address causes for the increase in mortality rates, but the authors note that differences in health care resources could compromise the accessibility, quality, and affordability of care in rural areas. Hospitals in small and remote communities have long struggled, and continued closures or conversions limit health care services in many places. The authors note that persistently higher rates of poverty, disability, and chronic disease in rural areas, compounded by fewer physicians per capita and the closure of hospitals, affect community health.

Roach said his past job as an epidemiologist included working with social vulnerability indexes, which factor in income, race, education, and access to resources like housing to get a sense of a community’s resilience against adverse health outcomes. A map of Arizona shows that rural counties and reservations have some of the highest vulnerability rankings.

Janice C. Probst, a retired professor at the University of South Carolina whose work focused on rural health, said many current rural health efforts are focused on sustaining hospitals, which she noted are essential sources of health care. But she said that may not be the best way to address the inequities.

“We may have to take a community approach,” said Probst, who reviewed the report before its release. “Not how do we keep the hospital in the community, but how do we keep the community alive at all?”

The disparities among demographics stood out to Probst, along with something else. She said the states with the highest rates of natural-cause mortality in rural areas included South Carolina, Mississippi, Georgia, Alabama, and others that have not expanded Medicaid, the joint federal and state health insurance program for low-income people, though there are efforts to expand it in some states, particularly Mississippi.

It’s an observation the USDA researchers make as well.

“Regionally, differences in State implementation of Medicaid expansion under the 2010 Affordable Care Act could have increased implications for uninsured rural residents in States without expansions by potentially influencing the frequency of medical care for those at risk,” they wrote.

Wesley James, founding executive director of the Center for Community Research and Evaluation, at the University of Memphis, said state lawmakers could address part of the problem by advocating for Medicaid expansion in their states, which would increase access to health care in rural areas. A large group of people want it, but politicians aren’t listening to their needs, he said. James also reviewed the report before it was published.

According to KFF polling, two-thirds of people living in nonexpansion states want their state to expand the health insurance program.

Morgan added the study focused on deaths that occurred prior to the covid-19 pandemic, which had a devastating effect in rural areas.

“Covid really changed the nature of public health in rural America,” he said. “I hope that this prompts Congress to direct the CDC to look at rural-urban life expectancies during covid and since covid to get a handle on what we’re actually seeing nationwide.”

In Arizona, the leading cause of death for people 45 to 64 in 2021 in both rural and urban areas was covid, according to Roach.


Jazmin Orozco Rodriguez wrote this story for KFF Health News.


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Experts warn health insurance premiums could rise an average of $1,000 a year for more than 2 million Californians who buy coverage on the individual marketplace, unless Congress extends subsidies from the Inflation Reduction Act.

The nonprofit Health Access California has federal data by congressional district.

Rachel Linn Gish, director of communications for the advocacy group, said for example, 140,000 people in the Central Valley alone benefit from the subsidies.

"As Congress is considering taking action to make these federal subsidies permanent, we want to make sure that Congress members know just how their constituents are going to be impacted by these health care decisions that they're about to make," Gish emphasized.

Linn Gish wants Congress to take up the issue soon because CoveredCA is working now to set rates for 2026. At a recent Senate Finance Committee hearing, Sen. Mike Crapo, R-Idaho, criticized the Inflation Reduction Act, which passed without a single Republican vote and said permanently extending the subsidies would contribute $325 billion to the federal deficit over 10 years.

A recent report from the University of California-Berkeley and the University of California-Los Angeles found enhanced tax credits through the Inflation Reduction Act save Californians $1.7 billion per year.

Gish pointed out the federal dollars have allowed state funds to flow toward programs to zero out deductibles and eliminate copays on many CoveredCA plans.

"If we lose the federal support for the premium help, then we may need to shift state dollars to backfill that," Gish cautioned. "Therefore consumers could also see spikes in their deductibles and other out-of-pocket costs for health care."

A recent study from UC Berkeley and UCLA predicted an additional 69,000 Californians could become uninsured due to increased premium costs if federal subsidies are allowed to expire next year.

Montana's expanded Medicaid program is set to expire next year. People who rely on it are calling on lawmakers for an extension but opponents argued Medicaid was never meant to be a long-term option for most people.

The Montana Legislature voted during its last session to expand the state's Medicaid program to cover an additional 85,000 people.

Megan Martin, a small-business owner and mother in Helena who relies on Medicaid, said she is out of health care options if the state does not extend it.

"I have looked and have been told that I could get health care off of our federal marketplace, which I don't qualify for," Martin explained. "That's terrifying because I don't make a ton of money, being a small-business owner. So, not having any other option is scary."

Gov. Greg Gianforte has not been clear on whether he supports an expansion but has said Medicaid should be a temporary program to help people get back on their feet. Data from KFF Health News show 9% fewer Montanans are covered under Medicaid now than before the pandemic.

Montana's Medicaid expansion is largely funded under the federal Affordable Care Act but is administered by the state, which is why expansion takes a legislative vote. Martin pointed out like many Montanans, she is working multiple jobs just to keep up with her family's cost of living, let alone being able to afford health care.

"How many more jobs do I have to get? How much more hustling do I have to do? How much more money do I have to put in my pocket, in order to make sure that we're all healthy?," Martin asked. "Nobody should have to worry about that, at the end of the day."

The Legislature is scheduled to consider extending the Medicaid expansion when lawmakers convene in January.


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A recent foodborne illness outbreak linked to deli meats is putting the spotlight on how these foods are regulated.

The listeria outbreak in Boar's Head products has led to 10 deaths and at least 59 people sickened across the country.

Jovana Kovacevic, associate professor of food science and technology at Oregon State University, said it is important to know listeria is prevalent in the natural environment. Kovacevic pointed out the United States has a zero-tolerance testing system for listeria, which is different from other countries and, counterintuitively, might do more harm than good than a system testing for certain levels of the bacteria.

"It would encourage industry to sample more," Kovacevic asserted. "And once they find positives, it would help them act before the food becomes contaminated and before any contaminated foods end up in the commerce."

Kovacevic pointed out listeria is most harmful for vulnerable populations, such as pregnant people, older people and those with compromised immune systems. Members of Congress recently wrote a letter to the U.S. Department of Agriculture over its concern that the agency wasn't able to prevent the outbreak.

But Kovacevic noted there has been progress on how the USDA and the Food and Drug Administration, which also monitors food safety in some situations, prevent foodborne illnesses. Still, she argued there is room for improvement.

"Standardizing our approach to listeria probably we would benefit from it," Kovacevic contended. "Consumers would benefit and the industry would benefit in terms of having the ability to look openly for listeria as opposed to fearing if they find any positive what's going to happen."

Kovacevic added there are ways consumers can prevent outbreaks, such as storing meats at the proper temperatures and cooking them thoroughly.

"There's just certain foods that are higher risk foods," Kovacevic explained. "If you're in that vulnerable group, you want to avoid those foods. So, we really need to do better to engage consumers in these discussions."


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