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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Population Health in Rural America in 2020: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25989.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Anna Nicholson, Rapporteur Roundtable on Population Health Improvement Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of Sciences and Aetna Foundation, Association of American Medical Colleges, Blue Shield California Foundation, BlueCross BlueShield of North Carolina, The California Endowment, Fannie E. Rippel Foundation/ReThink Health, Geisinger, Jefferson University, The Kresge Foundation, National Association of County and City Health Officials, Nemours, New York State Health Foundation, Robert Wood Johnson Foundation, Samueli Foundation, The University of Texas at Austin, and Wake Forest Baptist Medical Center. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25989 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Population health in rural America in 2020: Proceedings of a workshop. Washing- ton, DC: The National Academies Press. https://doi.org/10.17226/25989. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Con- gress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process, and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opin- ions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

WORKSHOP PLANNING COMMITTEE1 TOM MORRIS (Chair), Federal Office of Rural Health Policy, Health Resources and Services Administration MICHAEL BIRD, Indian Health Council, Inc. ALVA FERDINAND, Southwest Rural Health Research Center, Texas A&M University ALANA KNUDSON, Walsh Center for Rural Health Analysis, NORC at the University of Chicago JOSÉ MONTERO, Center for State, Tribal, Local, and Territorial Support, Centers for Disease Control and Prevention KAREN MURPHY, The Steele Institute for Health Innovation, Geisinger LARS PETERSON, Rural & Underserved Health Research Center, University of Kentucky 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. v PREPUBLICATION COPY—Uncorrected Proofs

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ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 SANNE MAGNAN (Co-Chair), Senior Fellow, HealthPartners Institute JOSHUA M. SHARFSTEIN (Co-Chair), Associate Dean for Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges DAWN ALLEY, Chief Strategy Officer, Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services JOHN AUERBACH, Executive Director, Trust for America’s Health CATHY BAASE, Chair, Board of Directors, Michigan Health Improvement Alliance; Consultant for Health Strategy, The Dow Chemical Company RAYMOND BAXTER, Trustee, Blue Shield of California Foundation DEBBIE I. CHANG, President and Chief Executive Officer, Blue Shield of California Foundation MARC N. GOUREVITCH, Professor and Chair, Department of Population Health, New York University Langone Health GARTH GRAHAM, President, Aetna Foundation MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare, Economics and Policy, FTI Consulting GARY R. GUNDERSON, Vice President, Faith Health, School of Divinity, Wake Forest University DORA HUGHES, Associate Research Professor of Health Policy and Management, Milken Institute School of Public Health, The George Washington University SHERI JOHNSON, Director, Population Health Institute; Acting Director, Robert Wood Johnson Foundation, Culture of Health Prize; Associate Professor, Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison WAYNE JONAS, Executive Director, Integrative Health Programs, H&S Ventures; Samueli Foundation ROBERT M. KAPLAN, Professor, Center for Advanced Study in the Behavioral Sciences, Stanford University MICHELLE LARKIN, Associate Vice President, Associate Chief of Staff, Robert Wood Johnson Foundation 1 The National Academies of Sciences, Engineering, and Medicines planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

MILTON LITTLE, President, United Way of Greater Atlanta PHYLLIS D. MEADOWS, Senior Fellow, Health Program, The Kresge Foundation BOBBY MILSTEIN, Director, ReThink Health JOSÉ T. MONTERO, Director, Office for State, Tribal, Local and Territorial Support; Deputy Director, Centers for Disease Control and Prevention JASON PURNELL, Associate Professor, Director, Health Equity Works, Brown School, Washington University in Saint Louis RAHUL RAJKUMAR, Senior Vice President and Chief Medical Officer, Blue Cross and Blue Shield of North Carolina LOURDES J. RODRIGUEZ, Senior Program Officer, St. David’s Foundation PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation KOSALI SIMON, Herman B. Wells Endowed Professor, Associate Vice Provost for Health Sciences, Paul H. O’Neill School of Public and Environmental Affairs, Indiana University HANH CAO YU, Chief Learning Officer, The California Endowment Health and Medicine Division Staff ALINA BACIU, Roundtable Director CARLA ALVARADO, Program Officer (until January 2021) HARIKA DYER, Senior Program Assistant AYSHIA COLETRANE, Senior Program Assistant ROSE M. MARTINEZ, Senior Board Director, Board on Population Health and Public Health Practice Consultant ANNA NICHOLSON, Rapporteur viii PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineer- ing, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: HARTLEY CARMICHAEL FELD, University of Kentucky College of Nursing DANIELLE LUCERO, University of Washington Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by MARTIN J. SEPULVEDA, IBM Corporation. He was responsible for making certain that an indepen- dent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xv 1 INTRODUCTION 1 Workshop Objectives, 2 Organization of the Proceedings, 3 2 RURAL AMERICA IN CONTEXT 5 Rural Demographics and Social Determinants of Health, 5 Structural Urbanism in Rural America, 12 Discussion, 17 3 RURAL HEALTH VITAL SIGNS 21 Why Is Mortality Higher in Rural America?, 21 Tribal Health Perspective, 25 Rural Data Challenges in the Healthy People 2020 Initiative, 29 Rural Healthy People Initiative: Processes and Rural Health Indicators, 31 The Effect of Racial Disparities in Rural Areas, 35 Discussion, 39 4 RURAL HEALTH CARE IN ACTION 45 Rural Health Care Landscape, 45 Tribal Health and Health Care in Rural Settings, 49 Wraparound Services: Implications for Rural America, 53 xi PREPUBLICATION COPY—Uncorrected Proofs

xii CONTENTS The Role of Community Health Workers in Addressing the Needs of Rural Americans, 57 Discussion, 63 5 ASSESSMENT AND IMPLEMENTATION STRATEGIES FOR IMPROVING THE HEALTH OF RURAL POPULATIONS 69 Community Health Needs Assessment, 69 Minnesota Integrated Behavioral Health Program to Support Population Health, 73 Role of Rural Development Hubs and Policy in Connecting Rural Development, Health, and Opportunity, 77 Innovations in Sustaining Rural Population Health, 83 Discussion, 88 6 RURAL HEALTH POLICY 93 Shifting Rural Health Policy and Practice Toward Value-Based Care, 93 Engaging Health Care Providers to Confront Rural America’s Health Care Crisis, 97 Tribal Rural Health Policy, 102 Congressional Response to COVID-19 for Rural America, 107 Discussion, 112 APPENDIXES A Speaker and Planning Committee Member Biosketches 117 B Workshop Agenda 131 C References 137 PREPUBLICATION COPY—Uncorrected Proofs

Boxes, Figures, and Table BOXES 1-1 Statement of Task, 2 3-1 Alaska Pacific University, 26 4-1 Community Health Workers’ Reflections on Their Roles, 59 5-1 Community Health Needs Assessment Process, 71 6-1 Margaret Mary Health, 94 FIGURES 2-1 Rural counties with more than 20 percent of their populations aged 65 years or older, 2017, 7 2-2 Race and ethnicity in rural areas, 9 3-1 Diverging trends in age-adjusted mortality in metro versus nonmetro areas in the United States, 23 3-2 Chronic disease burden by race and ethnicity for diabetes, 34 4-1 Wraparound services to address social determinants of health, 54 xiii PREPUBLICATION COPY—Uncorrected Proofs

xiv BOXES, FIGURES, AND TABLE 5-1 Blueprint for action for improving community health through innovations in financing, 86 TABLE 3-1 Top Rural Health Priorities Identified by Rural Healthy People 2010 and Rural Healthy People 2020, 33 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations ACO accountable care organization AHRQ Agency for Healthcare Research and Quality ATHS Alaska Tribal Health System BPC Bipartisan Policy Center CAH critical access hospital CARES Coronavirus Aid, Relief, and Economic Security CCCHC Coal Country Community Health Center CDC Centers for Disease Control and Prevention CDC WONDER CDC Wide-ranging Online Data for Epidemiologic Research CHNA community health needs assessment CHR community health representative CHW community health worker CMS Centers for Medicare & Medicaid Services COPD chronic obstructive pulmonary disease COVID-19 coronavirus disease 2019 EHR electronic health record FQHC federally qualified health center xv PREPUBLICATION COPY—Uncorrected Proofs

xvi ACRONYMS AND ABBREVIATIONS HHS Department of Health and Human Services HP 2020 Healthy People 2020 HRSA Health Resources and Services Administration IBH integrated behavioral health ICU intensive care unit IHCIA Indian Health Care Improvement Act IHS Indian Health Service KFF Kaiser Family Foundation medevac medical evacuation metro metropolitan PPE personal protective equipment PPP Paycheck Protection Program RAP recommendation adoption progress SBA Small Business Administration SDOH social determinants of health SMC Sakakawea Medical Center PREPUBLICATION COPY—Uncorrected Proofs

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Rural America is economically, socially, culturally, geographically, and demographically diverse. This multidimensional diversity presents complex challenges and unique opportunities related to delivering health care and improving health outcomes and health equity in rural communities.

To explore issues related to population health in rural America, the Roundtable on Population Health Improvement of the Board on Population Health and Public Health Practice of the National Academies of Sciences, Engineering, and Medicine convened a public virtual workshop, "Population Health in Rural America in 2020" on June 24-25, 2020. The workshop planning committee was composed of rural health experts representing public health, health care, and tribal health. Presentations and discussions focused on rural America in context, rural health vital signs, rural health care in action,assessment and implementation strategies for improving the health and health equity in rural populations, and rural health policy.This Proceedings of a Workshop summarizes the presentations and discussions from the workshop.

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