the health care infrastructure: the elderly have a greater need for health care services, especially for chronic disease management and long-term care. Rural populations also exhibit poorer health behaviors (i.e., higher rates of smoking and obesity and lower rates of exercise). Compared with urban residents, rural populations tend to have lower levels of income and education and higher rates of unemployment. Further, uninsurance rates are higher in rural than in urban counties. Thus, in rural areas there is a greater need for health care safety net providers. Finally, distances to health care providers are longer in rural areas.

Rural areas have a strong sense of community responsibility and propensity toward collaboration. As a result, they are adept at devising unique and creative ways to build social and physical infrastructures needed to provide the services that urban areas take for granted.

Generally, there are fewer health care organizations and professionals of all kinds in rural areas, and the availability of health care services varies widely. Some rural communities adjacent to urban centers have access to the full range of health care services, while remote villages and isolated towns may have few if any medical resources. Those providers that are located in rural areas are characterized by less choice and competition, and some have broadened their scope of practice to accommodate the needs of the local community. For most rural communities, retaining workforce capacity and health care services—whether primary care, emergency, hospital care, long-term care, mental health and substance abuse, oral health, or public health—has been a continuing challenge.

RURAL HEALTH POLICY

Making correct decisions on rural health policy is contingent on understanding the unique characteristics of the communities and conditions in which health care is delivered. Rural communities are heterogeneous, differing in population density, remoteness from urban areas, and the cultural norms of the regions of which they are part. As a result, they vary in their demographic, environmental, economic, and social characteristics. These differences influence the magnitude and types of health problems communities face.

National health policy has been increasingly responsive to rural health needs and problems. Over the years since 1983, Congress has created special categories of rural hospitals that receive either cost-based payment or elevated Medicare payments: rural referral centers, sole community hospi-



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