1 The Top 10 Rural Issues for Health

Rural people and rural communities are faced with many of the same health care issues and challenges confronting the rest of the nation—exploding heath care costs, large numbers of uninsured and underinsured, and an overextended health care infrastructure. However, there are numerous unique health care issues facing rural people and rural places. This is surely not an exhaustive list of those issues; it is our view of the Top 10 rural issues that should be addressed in health care reform legislation. As the debate over federal health care system reform takes place in Congress, we hope this list can be used as a checklist against which any bill or policy proposal can be measured to determine its value and effectiveness for rural America. An Economy Based on Self-Employment and Small Businesses The rural economy is unique in its composition, making issues of uninsurance and underinsurance more prominent in rural areas. Since the late 1990s, rural areas have witnessed a significant decline in manufacturing jobs and a rise in service sector employment, losing jobs with higher rates of employer-sponsored health insurance while gaining jobs with much lower rates of employer-sponsored coverage.4 The lack of employer-sponsored health insurance is particularly acute for low-skilled jobs, which are more common in rural areas.4 The rural economy is largely based on self-employment and small businesses. Since 1969, the number of self-employed workers in rural areas has grown by over 240 percent (by comparison, rural wage and salary worker