2021 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

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RHQ is pleased to present our fifth annual U.S. Rural Health Report Card.

Each state’s individual report card page includes a complete list of all the indicators that went into that state’s final score, and also includes a detailed discussion of “What’s Good” and “What Needs Work” in the state.

In this issue, you will see the effects of broadband access, maternal healthcare access, and dental care access. Some states improved tremendously in rural healthcare access, while others stayed in last year’s rankings or went down.

As always, 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 shine a light on healthcare success stories and improvements made by those who take direct action to reduce health disparities.

We hope the information provided is of assistance to all rural health stakeholders in helping to craft long-term effective solutions.

This research was supported by Texas Tech University Health Sciences Center and the F. Marie Hall Institute for Rural and Community Health.

We thank our colleagues who provided expertise and greatly assisted in the creation of the 2021 U.S. Rural Health Report Card, including Billy U. Philips, Ph.D., Gipsy Bocanegra, Ph.D., Grace Fosu, M.S., Diana Vargas-Gutierrez, Ph.D., and Miguel Carrasco.


The key findings for each state are summarized in each of the individual state report cards that follow this section. 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 indicating each state’s 2020 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.

The percentage difference of the urban-rural divide is expressed as the result of the absolute value of the difference between the age-adjusted mortality rate of rural counties and the age-adjusted mortality rate of the urban counties, all divided by the average of the sum of the age-adjusted mortality rates for both rural and urban counties of the same state (see below for formula).2

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 2020 rankings at a glance.


  1. Center for Disease Control and Prevention, Wonder (2019)
  2. County Health Rankings & Roadmaps Report (2022)
  3. Federal Communications Commission (FCC), Fourteenth Broadband Deployment Report 2021 Release
  4. Health Resources and Services Administration, U.S. Department of Health and Human Services, Area Health Resources File (AHRF) 2020-21 Release
  5. United States Census Bureau, Population data (2019)
  6. United States Census Bureau, American Community Survey (ACS) 2020 5-year Estimates Data Profiles
  7. United States Census Bureau, 2010 Census Regions and Divisions of the United States
  8. United States Department of Agriculture, 2013 Rural-Urban Continuum Codes
  9. SAS Statistical Package 9.4
  10. Microsoft Excel 2019 16.0.
    2 The formula for percentage difference for urban-rural divide is
    %D = (|n1 – n2|)/((n1 + n2 )/(2 )) x 100 (n1 = rural age adjusted
    mortality rate, n2 = urban age adjusted mortality rate)
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Candice Clark is the editor in chief of Rural Health Quarterly and a senior editor for the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.