group, or consider themselves multiracial. Of the primary groups, 43 percent live in 356 counties where they constitute one-third or more of the population.

African Americans are well distributed across the South’s lowland districts from southern Maryland through Louisiana. Although the 1990s brought gains in education and income, many difficulties persist for African American residents, who are predominately lower-income (e.g., lack of transportation, lack of affordable health care, poor housing). Native Americans are clustered in the northern High Plains, the Four Corners region in the Southwest, and Alaska. Counties in the first two regions contain reservations on which Native Americans are exercising greater economic and political control; however, poverty and unemployment remain high. For Alaska Natives, low population density and isolation from major population centers severely limit economic development prospects and increase health care delivery costs. High population concentrations of rural Hispanics remain in counties along the Rio Grande Valley, from the headwaters in southern Colorado to the Gulf of Mexico; however, about 50 percent now live outside the Southwest. Growing geographic dispersion has increased rural racial/ethnic diversity in all regions, particularly the Midwest and Southeast.

Generally, rural counties with high minority populations show signs of economic disadvantage. Minorities often live in isolated communities or neighborhoods where poverty is high, opportunity is low, and economic benefits from education and training are limited. Many who acquire education or technical skills must apply them elsewhere. Because of their socioeconomic status, minority groups tend to rely heavily on safety net services supported by federal and state programs, and resources for these programs are often inadequate (Rosenblatt, 2000).

While minority groups have many commonalities, some groups have distinct health care needs. By the end of the 1990s, Hispanics accounted for over 25 percent of the population growth in rural counties, with their population ranging from 8 percent in the Midwest to 18–29 percent in other rural regions (ERS, 2004). A large percentage of rural Hispanics work in agriculture as relatively low-paid, seasonal or part-time farm laborers, and many are uninsured (Ricketts, 1999). Hispanics also tend to have higher fertility levels, lower median ages, and larger household sizes (with more children and fewer elderly) (Beale and Cromartie, 2004). Rural communities with large populations of Hispanics need to ensure the availability of safety net programs that provide primary care and obstetric and pediatric services, and can address language and literacy barriers.

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