This research note presents a new perspective on the rural mortality penalty in the United States. While previous work has documented a growing rural mortality penalty, there has been a lack of attention to heterogeneity in trends at the intersection of region, race, and ethnicity. We use age-adjusted mortality rates from the Centers for Disease Control and Prevention to examine the rural mortality penalty by region, race, and ethnicity for 1999–2016 (N = 44,792,050 deaths) and stratify by 2006 National Center for Health Statistics metropolitan–nonmetropolitan classifications. We find substantial variation at the intersection of region, race, and ethnicity, revealing heterogeneity in the rural penalty and—in some cases—a rural mortality advantage. For the Black/African American population, the rural mortality penalty is observed only in the South. On the other hand, for Hispanic/Latino populations, a small but persistent rural mortality penalty is present only in the South and the West. There is a rural mortality penalty in all regions for White and American Indian/Alaska Native populations. However, for the latter, there is substantial variation in the magnitude of the penalty by region of residence. This research documents heterogeneous patterns when the rural mortality penalty is analyzed by region, race, and ethnicity in the United States.
Prior to the late 1900s, age-adjusted mortality rates were higher in urban than in rural areas of the United States. High population density and a lack of public health and sanitation measures left residents of urban centers more prone to disease and illness compared with rural residents, who were more dispersed (Haines 2001). However, following public health improvements, urban mortality rates declined faster than rural mortality rates and subsequently the urban penalty shrank and largely disappeared (Cutler and Miller 2005; Haines 2001). Differential rates in declining mortality eventually led to a rural mortality penalty, also known as a nonmetropolitan mortality penalty. The rural penalty first emerged in the 1990s (Cosby et al. 2008; James 2014). Greater decreases in heart disease and cancer deaths in urban areas than in rural areas contributed to this rural mortality penalty (Cossman et al. 2010), as did lower access to health care in rural areas than in urban areas (Cosby et al. 2019; James and Cossman 2017).
However, the rural mortality penalty is not homogeneous across race and ethnicity. Even at its emergence, the penalty first appeared in the 1980s for the White population and in the 1990s for the Black/African American population (James and Cossman 2017). In addition to different onsets, the depth of the penalty also varied between the White and Black populations (James and Cossman 2017; Miller and Vasan 2021). However, the extent of this penalty for other racial and ethnic groups within rural areas has received less attention, as most studies have focused solely on Black–White disparities in the rural mortality penalty (e.g., Ferdows et al. 2020; James and Cossman 2017). An exception is a study by Singh and Siahpush (2014), which found that the largest rural mortality penalty from 2005 to 2009 was for American Indian and Alaska Native populations. However, determining if and to what extent the rural mortality penalty exists and has changed over time for Hispanic/Latino, Asian and Pacific Islander, and American Indian and Alaska Native populations has received very little attention.
In addition, there are regional disparities in the rural mortality penalty (Hoffman and Holmes 2017). Some evidence points to a more severe penalty in the South compared with other U.S. regions (James 2014). Miller and Vasan (2021) used the term Southern rural mortality penalty to refer to compounding regional and rural mortality disadvantages, which they argued is also more severe for the Black/African American population than for their White counterparts. Their work, in particular, raises important questions about the intersection of regional and ethnoracial disparities in the rural mortality penalty. However, prior work has typically focused on just regional differences for the overall population or focused solely on one racial group (e.g., Hoffman and Holmes 2017; Monnat 2020). Despite the growing interest in the rural mortality penalty, there is still a gap in knowledge concerning the heterogeneity found at the intersection of region, race, and ethnicity.
Therefore, in this research note we (1) examine trends in the rural mortality penalty by race and ethnicity from 1999 to 2016 and (2) determine if these trends persist for all ethnoracial groups when stratified by region.
Data and Methods
Data and Measures
To examine trends in the rural mortality penalty by region of residence, race, and ethnicity for the entire United States, we used publicly available age-adjusted mortality rates by region and race and ethnicity from the compressed mortality files, which we extracted from the Centers for Disease Control and Prevention's (CDC) Wide-ranging Online Data for Epidemiological Research (WONDER) platform for 1999–2016 (CDC 2017). Age-adjusted rates for metropolitan–nonmetropolitan classification were not available for subsequent years. Region of residence, hereafter referred to as region, was measured using the U.S. Census Bureau classification scheme consisting of four categories: Northeast, South, Midwest, and West; it has been employed in the study of spatial disparities in the past (Roberts et al. 2016). Race and ethnicity were measured using five mutually exclusive categories. First, we extracted deaths for Hispanic/Latino decedents for the period of analysis. For instances where decedent's ethnicity was not recorded as Hispanic/Latino, we extracted deaths using the following four non-Hispanic/Latino racial categories: American Indian/Alaska Native, Asian/Pacific Islander, Black/African American, and White.
We used the 2006 National Center for Health Statistics (NCHS) Urban–Rural Classification Scheme to determine if the deaths occurred among rural or urban residents.1 This system classifies counties as Large Central Metro, Large Fringe Metro, Medium Metro, Small Metro, Micropolitan, and Noncore. Deaths of residents from counties in the first five categories were classified as urban, and those from the last category were classified as rural. Use of this classification across the period of analysis eliminates the possibility of county reclassification, which can influence mortality comparisons (Brooks et al. 2020).
Table 1 presents the racial and ethnic composition for the United States by region and rural–urban classification for 2016 using population estimates produced by the U.S. Census Bureau and available through CDC WONDER. The distribution of ethnoracial groups varies by region and rural–urban classification. In 2016, the South was home to the largest relative shares of Black/African American (9.06%), White (8.07%), and Hispanic (3.64%) rural residents. The West was home to the largest relative shares of rural Asian/Pacific Islander (1.75%) and rural American Indian/Alaska Native residents (17.79%). In summary, there is a great deal of ethnoracial heterogeneity across regions and by rural or urban counties.
Using the age-adjusted mortality rates provided by the CDC, we calculated rural–urban mortality rate ratios, hereafter referred to as rate ratios, to show if and to what extent a penalty exists for rural residents by region and race and ethnicity. The rate ratios were calculated by dividing the age-adjusted mortality rates for rural areas by the age-adjusted mortality rates for urban areas and multiplying the result by 100. If the ratio is equal to 100, rates are equal. If the rate ratio exceeds 100, a rural mortality penalty exists. If the rate ratio is lower than 100, a rural mortality advantage exists.
Analysis consisted of four stages. To examine trends in the rural mortality penalty by race and ethnicity, we present the age-adjusted mortality rates by race and ethnicity and rural–urban classification (Figure 1) and rate ratios by race and ethnicity (Figure 2) for 1999–2016. To evaluate how region and race and ethnicity intersect to shape patterns in the rural penalty, we present age-adjusted mortality rates by region and race and ethnicity and by rural–urban classification (Figure 3) and present rate ratios for each region and by race and ethnicity (Figure 4). Where we present rate ratios, we identify the point of similar rates as a dashed line (Figures 2 and 4). Analyses were conducted in RStudio (using ggplot2 for data visualizations).
Figure 1 shows age-adjusted mortality rates by race and ethnicity and rural–urban classification from 1999 to 2016. For all racial and ethnic groups, age-adjusted mortality rates were higher in rural counties. Overall, this gap increased over time. This is also true for the Black/African American and White populations. The gap was largest for American Indian/Alaska Native populations. While the age-adjusted mortality rates declined for almost all ethnoracial groups living in urban areas, this was not the case for the American Indian/Alaska Native population, and the magnitude of decline varied substantially across groups.
Descriptive analyses of rate ratios for age-adjusted mortality rates nationally affirm a persistent rural mortality penalty for the overall population and across all ethnoracial groups (Figure 2). Findings also indicate that the rural penalty has been most persistently pronounced for American Indians/Alaska Natives. The relatively larger rural mortality penalty for Asians/Pacific Islanders compared with other ethnoracial groups has shrunk over time, largely because of increasing rural penalties among the Black/African American and White populations. From 1999 to 2016, the rural mortality penalty declined for the American Indian/Alaska Native, Asian/Pacific Islander, and Hispanic/Latino populations. By 2016, the penalty for the Hispanic/Latino population was the smallest across all ethnoracial groups. This is not attributable solely to improvements for the Hispanic/Latino population, but is due to worsening penalties for Black/African American and White populations.
Figure 3 illustrates age-adjusted mortality rates by region and race and ethnicity for 1999–2016. Each column represents an ethnoracial group, and each row represents a region. For the Asian/Pacific Islander population, the age-adjusted rural mortality rate is only consistently higher than that of urban areas in the West. For American Indian/Alaska Native populations, the age-adjusted rural mortality rate is higher across all four regions, though declines are evident in the Midwest and Northeast. Among the Black/African American population, the age-adjusted rural mortality rate is higher only in the South. In fact, the rural rates for the Black/African American population are lower than the corresponding urban rates in the West, Midwest, and Northeast, showing a rural mortality advantage. Among the Hispanic/Latino population, age-adjusted rural mortality rates were only persistently higher than those of urban areas in the West. Finally, among the White population, age-adjusted mortality rates were higher for rural populations across all regions, but were largest in the South.
Figure 4 presents the rate ratios by race and ethnicity and region between 1999 and 2016 as a means of showing the relative magnitude of rural–urban differences. The first panel presents the pattern for the overall population by region. Subsequent panels present the patterns by race and ethnicity and by region. Overall, there is a growing rural mortality penalty across all regions. However, when stratified by race and ethnicity, there is a great deal of heterogeneity. First, American Indian/Alaska Native populations experienced a persistent and notable rural mortality penalty across all regions. Trends for Asian/Pacific Islander populations are more heterogeneous across regions, with the largest rural mortality penalty in the West and—at times—rural mortality advantages in the Northeast, Midwest, and South. The rural mortality penalty exists for the Black/African American population only in the South, and it is growing. In the Midwest, Northeast, and West, there is a rural mortality advantage for the Black/African American population. Similarly, there is a rural mortality advantage for the Hispanic/Latino population in the Northeast, as well as a small advantage emerging in the Midwest. Only in the West and South is there a persistent and notable rural mortality penalty for the Hispanic/Latino population. Finally, there is a rural mortality penalty for Whites across all regions, but the penalty is relatively small and only recently emerging for those in the Midwest. The highest rural mortality penalty for the White population is observed in the South.
Previous work has documented a rural mortality penalty in the United States (Cosby et al. 2008; James 2014). While recent findings suggest some heterogeneity in this penalty across region or race and ethnicity, our review of existing scholarship found that no previous studies have examined the intersection of these factors. We find that although the rural mortality penalty has been assumed to be a universal pattern, there are marked heterogeneous patterns in terms of magnitude and direction by region and race and ethnicity. Moreover, there is some evidence of a rural mortality advantage for some racially and ethnically minoritized groups in some regions; advantages are more evident for the Black/African American and Hispanic/Latino populations. In particular, the ethnoracial minority disadvantage in rural areas is more evident in regions that are home to larger relative shares of both ethnoracial groups.
Our findings affirm a rural mortality penalty for all racial and ethnic groups when region was not accounted for. In addition, our findings affirm previous work showing a growing rural mortality penalty overall and by region (Hoffman and Holmes 2017; James and Cossman 2017). The results for racially and ethnically minoritized populations are consistent with work by Singh and Siahpush (2014), who also found larger rural penalties for American Indians and Alaska Natives; yet, our analysis reveals substantial variation by region. Only for the White and American Indian/Alaska Native populations were there consistent rural penalties across all regions. The penalty for the White population is small but growing across all regions, with the highest rural mortality penalty observed in the South. For the Asian/Pacific Islander population, the penalty was large and persistent only in the West, which is where larger shares of the rural Asian/Pacific Islander population live (see Table 1). For the Black/African American population, the rural penalty exists only in the South, where the majority of the rural Black/African American population lives. These findings build on previous work (James 2014; Miller and Vasan 2021) showing more severe penalties in the South for the Black/African American population. Similarly, for the Hispanic/Latino population, the penalty is present only in the South and West. Therefore, rural penalties for the Black/African American, Hispanic/Latino, and Asian/Pacific Islander populations are regionally heterogeneous, but are larger or more persistent in the regions where their populations are more spatially clustered.
These findings establish that there is heterogeneity in the rural mortality penalty at the intersection of region and race and ethnicity, and they elicit additional questions that should be pursued in future research. In particular, new work should explore which factors (e.g., migrant selectivity, economic dependencies, historical residential patterns, or clustering in spatially affluent areas) shape the rural advantage for Black/African American, Hispanic/Latino, and Asian/Pacific Islander populations in regions where their populations are relatively small. Notably, previous research has explored the existence of the rural penalty by sex (Monnat 2020; Singh and Siahpush 2014). This research note serves as a basis for the exploration of how ubiquitous these patterns are at the intersection of sex with other factors that may exacerbate or attenuate the gaps observed at the national level. However, such pursuits are beyond the scope of this research note and warrant attention to systems that may be shaping those patterns and more localized disparities.
This analysis should be evaluated by considering its strengths and limitations. The main strength is that we use age-adjusted mortality rates produced by the CDC, which reduces the possibility of miscalculation of these rates. A second strength is that the age-adjusted rates are derived from population-level data, which allows for direct comparisons while accounting for age composition with high levels of reliability. One limitation is the unavailability of the compressed mortality file for 2017–2020, which precludes us from studying more recent trends in age-adjusted mortality rates by metropolitan classification. The Underlying Causes of Death mortality file available through CDC WONDER includes data until 2020. While this platform does provide the data necessary to calculate Crude Death Rates (CDRs), it does not provide age-standardized rates using the rural–urban dichotomous classification. While the examination of CDR is not ideal, as it ignores the role that age composition plays in rural–urban differences, we replicated our analysis with this metric and obtained results consistent with those presented in the main analyses (see Figure S1 in the online appendix). Further, 123,016 death records (0.27% of total deaths) had “Not Stated” in their Hispanic ethnicity. These observations were excluded from the analysis. Given the reduced number of observations that were excluded and the fact that they were evenly distributed over the period of analysis, the results presented here are reliable. Finally, as always when working with mortality data, it is possible that misclassification of race and ethnicity occurs by coroners, leading to mismatching. While this has the potential to affect the results, the authors are not aware of any evidence that mismatching is more likely to occur in rural areas or particular regions of the United States.
In this research note, we examined the rural mortality penalty across region and race and ethnicity from 1999 to 2016. Our findings suggest that the intersection of regional context and race and ethnicity shape heterogeneous mortality penalties, in some cases deviating from patterns currently discussed in demographic scholarship. Future research should explore factors that produce this heterogeneity by engaging with the emerging literature on the structural and systemic factors that shape health and mortality dynamics across the United States. Broadly speaking, researchers should pay closer attention to demographic phenomena that are assumed to be universal, as it may be possible, as we have shown, that these are not applicable for some portions of the population. As rural America becomes more diverse, it is essential to understand if and how the rural mortality penalty applies to racially and ethnically minoritized groups within different regions of the United States.
The authors acknowledge support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development–funded Population Research Institute at The Pennsylvania State University (P2CHD041025), the National Institute on Aging (NIA)–funded Interdisciplinary Network on Rural Population Health and Aging (R24 AG065159), the U.S. Department of Agriculture's National Institute of Food and Agriculture and Multistate Research Project W5001: Rural Population Change and Adaptation in the Context of Health, Economic, and Environmental Shocks and Stressors (#PEN04796, Accession #7003407), and Penn State's Social Sciences Research Institute. A.S. and D.R. are supported by NIA R21AG083393.
Criteria used to define this NCHS urban–rural classification can be found at https://www.cdc.gov/nchs/data_access/urban_rural.htm.