On November 16, we observe National Rural Health Day, a time to recognize the approximate 65 million people, or one in five Americans, living in rural America and the potential barriers to healthcare they might face. While rural areas have more land area, fewer people, scenic landscapes, and a strong sense of community, residents often face barriers in accessing healthcare services (PDF | 2.2 MB) needed to reduce disparities between rural and urban health outcomes.

A Portrait of Health in Rural America

According to the National Institutes of Health (NIH), rural Americans are more likely to die prematurely from the nation’s leading causes of death, including heart disease, cancer, lung disease, and stroke. They also have higher rates of obesity and diabetes, and they are at greater risk of fatal car crashes, suicide, and drug overdoses. In addition, surveys indicate that rural communities struggle with recruiting and retaining healthcare providers and experience ongoing, long-term healthcare provider shortages.

The Centers for Disease Control and Prevention (CDC) reports that, in the past two decades, suicide rates have been consistently higher in rural areas than in urban areas. Between 2000 and 2020, suicide rates increased 46 percent in non-metro areas compared to 27.3 percent in metro areas. CDC additionally reports that the rates of drug overdose deaths are rising in rural areas, surpassing rates in urban areas. Although the percentage of people reporting illicit drug use is lower in rural areas, the effects of use appear to be higher. In fact, the U.S. opioid epidemic has disproportionately affected specific rural regions, with 1600 percent and 1141 percent increases in opioid-related deaths in the rural Midwest and northeast between 1999 and 2016. In comparison, opioid mortality increased by 158 percent in urban areas during the same time.

Responding to Behavioral Health Disparities

Enhancing access to suicide prevention and mental health services and preventing substance use and overdose are top priorities emphasized in the new SAMHSA 2023-2026 Strategic Plan. Equity, one of the guiding principles outlined in the Strategic Plan, involves ensuring that everyone, including individuals living in rural America, has a fair and just opportunity to be as healthy as possible. In conjunction with providing access to quality services, this involves addressing factors that impact behavioral health outcomes, such as employment and housing stability, insurance status, proximity to services, and culturally responsive care. For these reasons, SAMHSA is committed to supporting rural communities to achieve better quality of life via its Rural Behavioral Health programs.

Spotlight on Rural Behavioral Health Programs

Two of SAMHSA’s Rural Behavioral Health programs include the Rural Opioid Technical Assistance Regional Center (ROTA-R) and Rural Emergency Medical Services (EMS) Training grant. ROTA-R is a regionally based, rural program that develops and disseminates high-quality training and technical assistance to address opioid and stimulant use. ROTA-R teams identify model programs and develop and refine regionally tailored prevention, harm reduction, treatment, and recovery activities for opioid use disorder and/or stimulant use disorder. The ROTA grantees conduct regional needs assessments, partners with leaders such as State and Tribal Opioid Response grantees, and offers tailored training and technical assistance, including a local toll-free resource line.

While the need for a strong and diverse rural EMS workforce with capacity to address behavioral health crisis care is high, training to build and maintain such a workforce is hard to access (PDF | 1.1 MB) in rural areas. To help meet this need, the EMS Training grant program provides support for rural EMS agencies operated by local or tribal government and rural non-profit EMS agencies. The purpose of this program is to recruit and train EMS personnel in rural areas, with a particular focus on addressing substance use disorders (SUD) and co-occurring substance use and mental disorders (COD). Recipients use the grant funds to strengthen rural EMS workforce through the maintenance of needed licensing and certifications while providing training on SUD, COD, and the principles of trauma-informed, recovery-based care for behavioral health emergencies. Despite real infrastructure challenges, Rural EMS Training grantees have reported notable accomplishments, such as having bolstered a greatly needed EMS workforce amidst a global pandemic and building training capacity that can sustain this workforce for the long-term. Grantees have repeatedly emphasized the role of the Rural EMS Training grant in allowing agencies to continue carrying out vital EMS functions, not only in the peak of the COVID-19 pandemic, but for years to come.

Serving Rural Americans Through 988

In 2020, Congress designated 988 to be operated through the existing National Suicide Prevention Lifeline. Given the capacity of 988 to provide crisis counseling services to anyone in any locality, it holds great potential to improve behavioral health crisis capacity in rural areas. 988 is one piece of a multi-faceted behavioral health crisis care continuum. Officials must continue building local crisis care infrastructure to ensure that rural callers can be referred to appropriate resources and facilities as needed, while partnering with behavioral health providers and emergency response. By leaning on rural America’s strong tradition of community-building and collaboration, 988 can integrate into a robust crisis care continuum to better serve these areas.

Rural areas are rich in community, culture, and resources. They are crucial sources of water, food, energy, and recreation for the nation, constituting 97 percent of America’s land mass and accounting for a large portion of the country’s vital natural resources. Observing Rural Health Day is an opportunity to bring attention to and honor rural healthcare providers, communities, organizations, and all stakeholders dedicated to securing good health in rural America.