Population Health
in Rural America
in 2020

PROCEEDINGS OF A WORKSHOP

Anna Nicholson, Rapporteur

Roundtable on Population Health Improvement

Board on Population Health and Public Health Practice

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

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This activity was supported by contracts between the National Academy of Sciences and Aetna Foundation, Association of American Medical Colleges, Blue Shield of California Foundation, BlueCross BlueShield of North Carolina, The California Endowment, Fannie E. Rippel Foundation/ReThink Health, Geisinger, The Kresge Foundation, National Association of County and City Health Officials, Nemours, New York State Health Foundation, Robert Wood Johnson Foundation, Samueli Foundation, The University of Texas at Austin, Thomas Jefferson University, and Wake Forest Baptist Medical Center. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-68527-6
International Standard Book Number-10: 0-309-68527-3
Digital Object Identifier: https://doi.org/10.17226/25989

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Population health in rural America in 2020: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25989.

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PLANNING COMMITTEE ON POPULATION HEALTH IN RURAL AMERICA IN 2020¹

TOM MORRIS (Chair), Federal Office of Rural Health Policy, Health Resources and Services Administration

MICHAEL BIRD, Indian Health Council

ALVA FERDINAND, Southwest Rural Health Research Center, Texas A&M University

ALANA KNUDSON, Walsh Center for Rural Health Analysis, NORC at the University of Chicago

JOSÉ T. MONTERO, Center for State, Tribal, Local, and Territorial Support; Centers for Disease Control and Prevention

KAREN MURPHY, The Steele Institute for Health Innovation, Geisinger

LARS PETERSON, Rural & Underserved Health Research Center, University of Kentucky

___________________

¹ The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution.

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ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT¹

SANNE MAGNAN (Co-Chair), Senior Fellow, HealthPartners Institute

JOSHUA M. SHARFSTEIN (Co-Chair), Associate Dean for Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health

PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges

DAWN ALLEY, Chief Strategy Officer, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services

JOHN AUERBACH, Executive Director, Trust for America’s Health

CATHY BAASE, Chair, Board of Directors, Michigan Health Improvement Alliance; Consultant for Health Strategy, The Dow Chemical Company

RAYMOND BAXTER, Trustee, Blue Shield of California Foundation

DEBBIE I. CHANG, President and Chief Executive Officer, Blue Shield of California Foundation

MARC N. GOUREVITCH, Professor and Chair, Department of Population Health, New York University Langone Health

GARTH GRAHAM, President, Aetna Foundation

MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare, Economics and Policy, FTI Consulting

GARY R. GUNDERSON, Vice President, Faith Health, School of Divinity, Wake Forest University

DORA HUGHES, Associate Research Professor of Health Policy and Management, Milken Institute School of Public Health, The George Washington University

SHERI JOHNSON, Director, Population Health Institute; Acting Director, Robert Wood Johnson Foundation, Culture of Health Prize; Associate Professor, Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison

WAYNE JONAS, Executive Director, Integrative Health Programs, H&S Ventures; Samueli Foundation

ROBERT M. KAPLAN, Professor, Center for Advanced Study in the Behavioral Sciences, Stanford University

MICHELLE LARKIN, Associate Vice President, Associate Chief of Staff, Robert Wood Johnson Foundation

___________________

¹ The National Academies of Sciences, Engineering, and Medicines planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution.

MILTON LITTLE, President, United Way of Greater Atlanta

PHYLLIS D. MEADOWS, Senior Fellow, Health Program, The Kresge Foundation

BOBBY MILSTEIN, Director, ReThink Health

JOSÉ T. MONTERO, Director, Center for State, Tribal, Local, and Territorial Support; Deputy Director, Centers for Disease Control and Prevention

WILLIE (BILLY) H. OGLESBY, Interim Dean, Jefferson College of Population Health, Thomas Jefferson University

JASON PURNELL, Associate Professor, Director, Health Equity Works, Brown School, Washington University in Saint Louis

RAHUL RAJKUMAR, Senior Vice President and Chief Medical Officer, BlueCross and BlueShield of North Carolina

LOURDES J. RODRIGUEZ, Senior Program Officer, St. David’s Foundation

PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation

KOSALI SIMON, Herman B. Wells Endowed Professor, Associate Vice Provost for Health Sciences, Paul H. O’Neill School of Public and Environmental Affairs, Indiana University

HANH CAO YU, Chief Learning Officer, The California Endowment

Health and Medicine Division Staff

ALINA BACIU, Roundtable Director

CARLA ALVARADO, Program Officer (through January 2021)

HARIKA DYER, Senior Program Assistant

AYSHIA COLETRANE, Senior Program Assistant (from October 2020)

ROSE M. MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice

Consultant

ANNA NICHOLSON, Rapporteur

Reviewers

This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.

We thank the following individuals for their review of this proceedings:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by MARTIN J. SEPULVEDA, IBM Corporation. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies.

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Contents

ACRONYMS AND ABBREVIATIONS

1 INTRODUCTION

Workshop Objectives

Organization of the Proceedings

2 RURAL AMERICA IN CONTEXT

Rural Demographics and Social Determinants of Health

Structural Urbanism in Rural America

Discussion

3 RURAL HEALTH VITAL SIGNS

Why Is Mortality Higher in Rural America?

Tribal Health Perspective

Rural Data Challenges in the Healthy People 2020 Initiative

Rural Healthy People Initiative: Processes and Rural Health Indicators

The Effect of Racial Disparities in Rural Areas

Discussion

4 RURAL HEALTH CARE IN ACTION

Rural Health Care Landscape

Tribal Health and Health Care in Rural Settings

Wraparound Services: Implications for Rural America

The Role of Community Health Workers in Addressing the Needs of Rural Americans

Discussion

5 ASSESSMENT AND IMPLEMENTATION STRATEGIES FOR IMPROVING THE HEALTH OF RURAL POPULATIONS

Community Health Needs Assessment

Minnesota Integrated Behavioral Health Program to Support Population Health

Role of Rural Development Hubs and Policy in Connecting Rural Development, Health, and Opportunity

Innovations in Sustaining Rural Population Health

Discussion

6 RURAL HEALTH POLICY

Shifting Rural Health Policy and Practice Toward Value-Based Care

Engaging Health Care Providers to Confront Rural America’s Health Care Crisis

Tribal Rural Health Policy

Congressional Response to COVID-19 for Rural America

Discussion

APPENDIXES

A Speaker and Planning Committee Member Biosketches

B Workshop Agenda

C References

Boxes, Figures, and Table

BOXES

1-1 Statement of Task

3-1 Alaska Pacific University

4-1 Community Health Workers’ Reflections on Their Roles

5-1 Community Health Needs Assessment Process

6-1 Margaret Mary Health

FIGURES

2-1 Rural counties with more than 20 percent of their populations aged 65 years or older, 2017

2-2 Race and ethnicity in rural areas

3-1 Diverging trends in age-adjusted mortality in metro versus nonmetro areas in the United States

3-2 Chronic disease burden by race and ethnicity for diabetes

4-1 Wraparound services to address social determinants of health

5-1 Blueprint for action for improving community health through innovations in financing

TABLE

3-1 Top Rural Health Priorities Identified by Rural Healthy People 2010 and Rural Healthy People 2020

Acronyms and Abbreviations