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2018 U.S. RURAL HEALTH REPORT CARD – Grading the state of rural health in America

RURAL REPORTS – Rural health reporting from across the nation and around the world

RHQ CONFERENCE CALENDAR – Upcoming U.S. rural health conferences


[dropcap]RHQ[/dropcap] is pleased to present our second annual U.S. Rural Health Report Card. Last year, we were humbled by the warm reception afforded our first attempt at ranking and grading states by rural health outcomes and access to care. We also learned a great deal from your feedback, and we’ve attempted to incorporate your suggestions into this year’s Report Card.

Each state’s individual report card page now includes a complete listing of all the indicators that went into that state’s final score, and each also includes a more detailed discussion of “What’s Good” and “What Needs Work” in the state. We’ve also begun to address what was perhaps the most glaring omission in last year’s report: Telemedicine access.

Telemedicine plays an increasingly vital role in rural health care nationwide, and adoption of the technology is advancing so rapidly we would be remiss to ignore it. Reliable national telehealth usage data is still hard to come by, however, so we chose to begin where every rural community interested in adopting telehealth solutions must also begin: Broadband access. Going forward, every state will receive a rural broadband access grade that will be factored into that state’s final Access to Care score. This Broadband Access grade replaces 2017’s Emergency Care Access grade, a measure of access to emergency care physicians that appears to have a weaker correlation to rural health outcomes than many other access measures.

We compiled this report to provide policymakers, practitioners and the public with a snapshot of each state’s rural health status relative to other states across the nation. These state report cards underscore ongoing challenges that face many rural communities, but they also highlight health care success stories and improvements made by those who take direct action to reduce rural health disparities. We hope that the information we are providing will be of assistance to all rural health stakeholders in helping to craft effective solutions.

This research was supported by the Texas Tech University Health Sciences Center and the F. Marie Hall Institute for Rural and Community Health. We thank our colleagues who provided insight and expertise that greatly assisted in the creation of the 2018 U.S. Rural Health Report Card, including Billy Philips, Catherine Hudson, Gordon Gong, Debra Curti, Luciano Boas, Miguel Carrasco and Traci Butler Carroll.


When it comes to defining rurality, counties are RHQ’s sole unit of measurement. This has the virtue of allowing us to use well-established and reliable data sources. Unfortunately, this means excluding three states and Washington D.C. from our study. While Delaware, New Jersey and Rhode Island each contain small pockets of rurality, these states, like D.C., are largely urbanized, and none contains a single county with a non-metropolitan population.

We combined data from all rural counties in a state, and the rural/urban status of a county is defined according to the 2013 Rural Urban Continuum Codes (RUCC); i.e., the rural area of a state is an aggregate of all rural counties in a state. All counties in the U.S. are sorted as either metropolitan (urban) or non-metropolitan (rural). RUCC forms a classification scheme that distinguishes metropolitan counties by the population size of their metro area, and nonmetropolitan counties by degree of urbanization and adjacency to a metro area.
The overall composite scores in the Report Card are calculated using 10 variables divided into three equally weighted categories: Mortality, Quality of Life and Access to Care.


Mortality includes age-adjusted mortality rates for all causes of death in all rural counties in a state. Mortality accounts for 1/3 of each state’s final composite score. Grades are also assigned to the top-five causes of death in each state’s report card for discussion purposes, but we use only the All-Cause Mortality rate (and not the rates of individual causes of death) to determine each state’s composite score, rank and grade.

Quality of Life includes the percentage of babies born in rural counties with a low birth weight (2010-2016), the percentage of rural residents who reported having poor general health (2016), the number of poor physical health days reported by rural residents in the past 30 days (2016) and the number of poor mental health days reported by rural residents in the past 30 days (2016). Each state’s combined access to “high-quality” broadband in 2016. Each state’s combined Access to Care score accounts for 1/3 of that state’s final composite score.

“High-quality” broadband access, a new metric added to the report cards this year, was defined by Congress in 2018 as the capability that allows users to “originate and receive high-quality voice, data, graphics, and video” services. The FCC retains the existing speed benchmark of 25 Mbps download/3 Mbps upload (25 Mbps/3 Mbps) for “high-quality” fixed services.

A variety of measures and data sources related to U.S. health care were reviewed for this study, but the three categories and ten variables selected appear to offer the most even-handed and accurate picture of the state of rural health across the nation. Other well-known national health rankings, like the County Health Rankings (CHR) model produced by the Robert Wood Johnson Foundation, rely heavily on a more holistic view of population health, but the RHQ U.S. Rural Health Report Card focuses instead on a narrow band of data related specifically to rural health outcomes and access. This choice should not be interpreted as a criticism of other models. Rather, RHQ’s approach takes as a given that social and economic factors exert a powerful influence on health. Our report card instead seeks to highlight a limited set of key variables in an attempt to create a clear snapshot of state and regional differences in rural health care delivery.



Each state was given a letter grade based on calculations using a Z-score. Grades were put into five traditional American grading categories: A, B, C, D and F. Positive and negative delineations (+ and -) were added to each letter grades except F to indicate the top three and bottom three performers in each quintile.

We used Z-scores to standardize each measure for each state relative to the average of all states where:

Z = (state value – average of all states) / (standard deviation of all states).

A positive Z-score indicates a value higher than the average of all states; a negative Z-score indicates a value for that state lower than the average of all states. Z scores for provider supplies (primary care physicians, dentists and psychiatrists) are reversed; i.e., a positive value is reversed to a negative one and negative one to a positive value.
For the 47 states included, each grade was based on their overall quintile ranking.


The key findings for each state are summarized in each of the individual state report cards in the PDF.

Each state’s final grade and overall rank appear prominently at the top of each page alongside a listing of each state’s grades in each of 10 differently weighted rural health measures. Below the final grade for each state, numbers and arrows indicate each state’s 2018 State Rural Health Rankings for the three equally weighted categories: Mortality, Quality of Life and Access to Care.

Each report card also includes a state map that delineates rural and urban counties by color (red means rural) along with a brief list of facts about each state’s rural population.
Finally, every report card offers a summary of “What’s Good,” “What Needs Work,” and the “Urban-Rural Divide” in state mortality rates. Urban-rural difference in mortality is defined as the result of the z-score of rural counties minus the z-score of urban counties of the same state; the county with the smallest value is ranked the highest.

In Figure 2, all nine U.S. Census regional divisions are numbered and color coded based on their final average rankings. The top third is in green, the middle third is yellow, and the bottom third is red. Further details about divisional rankings (composite scores calculated using all 10 health variables) are detailed in Table 3. The map in Figure 3 color codes each state individually and provides their final 2018 rankings at a glance.

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RELATED: Rural Health Report Cards: Why They Matter


  1. United States Department of Agriculture, Rural-Urban Continuum Codes
  2. United States Census Bureau, Census Regions and Divisions of the United States
  3. Centers for Disease Control and Prevention, National Center for Health Statistics
  4. Robert Wood Johnson Foundation, County Health Rankings
  5. Health Resources and Services Administration of U.S. Department of Health and Human Services.
  6. United States Census Bureau. American Community Survey, American Factfinder (S2701)
  7. Federal Communications Commission, 2018 Broadband Deployment Report
  8. SAS Statistical Package 9.4


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Scott G. Phillips is the retired editor in chief of Rural Health Quarterly.

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