Legislative and Legal Approaches to Address Key Rural Health Issues

October 18, 2018|3:38 p.m.| ASTHO Staff

This week, National Public Radio, the Robert Wood Johnson Foundation, and the Harvard T.H. Chan School of Public Health released the Life in Rural America report. Based on a survey of 1,300 adults ages 18 or older living in the rural United States, the report reveals the views and experiences of rural Americans facing a number of economic and health issues.

More than 46 million Americans live in rural areas. Often, those living in rural areas are confronted with a lack of access to healthcare, exposure to environmental hazards, higher rates of poverty—experiences that lead to an increased risk of poor health outcomes. Higher rates of tobacco use and obesity can also be found in rural areas. According to the report, substance misuse or abuse (including opioids) and suicide are major health issues facing rural America and these problems have gotten worse over the past five years. In addition, rural Americans identified access to care as a challenge impacting the health of their communities.

When asked about the solutions to major problems impacting the health of their communities, 58 percent of those surveyed believe they need outside help and 30 percent believe state government will play the greatest role. In addressing rural health issues, state policymakers often turn to public health agencies as the appropriate, responsible government actor. Below is a brief overview of recent state legislation and policy authorizing state health agencies to address some of the health issues impacting those in rural areas.

Substance Misuse and Abuse

Drug overdose is now the leading cause of injury death in the United States. While the rate of drug use is lower in rural areas than in urban areas, the fatal overdose rate in rural areas continues to rise. Almost one-quarter of rural Americans say that substance use or abuse is the most urgent health problem currently facing their community. A majority of rural Americans (57%) feel that addiction to opioids in their local community is a serious problem, including one-third (33%) who say it is a very serious problem. Over the past couple of years, some states have issued emergency declarations to address substance misuse and abuse. Emergency declarations provide an opportunity to quickly respond to an emergency by reallocating state funds, mandating data sharing, and strengthening collaboration among public health and law enforcement agencies.

In February 2017, Alaska Gov. Bill Walker declared an emergency and authorized the commissioner and state medical officer of the Alaska Department of Health and Social Services to coordinate the establishment of a statewide overdose response program and a statewide standing order for dispensing naloxone, a medication used to reverse opioid overdoses. Jay Butler, MD, the agency’s chief medical officer, used this authority to issue a statewide standing order for naloxone.

In January 2018, Pennsylvania Gov. Tom Wolf signed a Proclamation of Disaster Emergency for the opioid epidemic to enhance a coordinated state and local response effort, increase access to treatment, increase data collection, and improve tools for law enforcement and families. The proclamation called for the establishment of an Opioid Unified Coordination Group consisting of the heads of executive branch agencies, including the department of health, tasked with preparing for, preventing, responding to, and mitigating the effects of the opioid crisis in Pennsylvania.


Suicide rates are higher in rural America than in urban America and the gap in suicide rates grew steadily from 1999 to 2015. Three in 10 rural Americans say suicide is a serious problem in their local community, including one in 10 who say it is very serious. The National Strategy for Suicide Prevention, as issued by the U.S. Surgeon General in 2012, recommends improving and expanding state, territorial, tribal, and local public health capacity to routinely collect, analyze, report, and use suicide-related data to implement prevention efforts and inform policy decisions. The use of state health agencies and professionals in reviewing suicides can lead to a greater understanding of the cause of death and the methods of preventing deaths.

The Montana legislature recognized that the prevention of suicide is a community responsibility and that community professionals have expertise that can be used to promote strategies and supports to prevent suicide. In 2013, Montana passed legislation establishing a suicide review team to review the circumstances related to suicides and make recommendations to the governor.

In 2018, the Tennessee legislature passed HB 1961 after the Tennessee Suicide Prevention Network declared suicide deaths a serious public health issue that have a tremendous impact on society and family. The bill, also called the “Suicide Prevention Act of 2018,” authorizes the commissioner of the Tennessee Department of Health to establish a suicide prevention program.

Access to Care

Access to healthcare was identified as one of the most urgent health problems currently facing rural communities by 11 percent of the survey respondents. Barriers to healthcare access in rural areas include lack of health insurance coverage, healthcare workforce shortages, distance and transportation challenges, social stigma and privacy issues, and poor health literacy. Many states use law and policy to address these challenges. For example, states have enacted and proposed legislation to use community health workers as a linkage to health and social services. They have also taken steps to require insurance coverage and reimbursement for treating opioid use disorders, improve maternal health through Medicaid expansion, and ensure that increased access to care aligns with achieving optimal health for all.

As state lawmakers continue to focus on improving health in rural areas, it is likely that they will give state health agencies increased authority to coordinate and implement targeted policies and programs to address the health issues identified by rural Americans. ASTHO will continue to track legislation and update members on this important public health issue.

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