Across the globe, people in rural areas tend to have poorer health and a harder time accessing health care than people in urban communities. These geographic disparities are especially stark in the United States, where about 15 percent of the population, or roughly 46 million people, live in rural areas. Recent research, based on the Commonwealth Fund’s 2020 International Health Policy Survey, found that the U.S. had more geography-based health disparities than did 10 other high-income countries, including Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom.

These disparities translate into significant health challenges. In the U.S., people living in rural communities have higher rates of chronic disease and suicide, worse maternal health, and limited access to care compared to adults in cities. Many factors contribute to these disparities, but in the U.S., the ability to afford health care stands out as a substantial contributor. People in rural communities in the U.S. report more trouble paying for care than do people in rural areas in any of the countries included in the analysis.

Rural Americans are most likely to skip needed care because of costs.

More than one-third of rural Americans reported skipping needed care because of costs. This is more than twice the rate of rural residents in six of the other countries in this analysis. In contrast, fewer than one of 10 rural residents in the U.K., Norway, and Sweden reported skipping needed care because of costs.

Rural Americans are most likely to struggle with medical bills.

Prior research consistently shows that the high cost of health services in the U.S. affects consumers with or without insurance coverage, leading to higher medical bills and medical debt. The survey found that nearly a quarter of rural Americans reported either serious problems paying medical bills or an inability to pay altogether. Fewer than one of 10 rural adults in nearly all the other countries surveyed reported struggling to pay their medical bills.