RURAL RUIN

In Upstate New York, Wilmington’s Roy Holzer and Willsboro’s Shaun Gillilland are archetypal rural town supervisors. Their offices in Essex County are understated and devoid of the sort of “glory wall” photos of them posing with notable state or national politicians that many elected officials favor. Supervisor is a mostly thankless job on the front lines of local governance: You maintain public services, fight for scarce revenue, and solve local political disputes. Most of your constituents are first-name-basis neighbors, and some have known you since you were a kid. When you show up for work at the town hall, it’s best to check your ego at the door.

Wilmington and Willsboro are two of eighteen townships in Essex County. Twelve miles east of Lake Placid, Wilmington is nestled in the shadow of Whiteface Mountain, the downhill skiing venue for the 1932 and 1980 Winter Olympics and a perennial attraction for winter skiers and summer hikers. On the eastern side of the county, perched on the idyllic shores of Lake Champlain, Willsboro’s marinas and lakefront launches are popular havens for recreational boaters and fishing enthusiasts.

Essex is a swing county in presidential politics: In fact, it is one of only eight U.S. counties carried by every presidential winner during the past seven consecutive election cycles, from Bill Clinton’s re-election victory in 1996 through Joe Biden’s 2020 win. (Only three counties currently have longer active streaks.) Holzer and Gillilland are Republicans who support U.S. representative Elise Stefanik and President Donald Trump. But neither is an ideological firebrand. Management and policy, not divisive partisanship, animate their daily routines. “Wilmington’s the kind of town a lot of people are longing for, especially now, the way our country is,” Holzer says proudly, noting that his town features a cordial mix of Republicans, Democrats, and independents. “You can still go to a local coffee shop and have a disagreement with somebody and then spend the day fishing with them. In the end, if you are having a personal problem, people are going to come to your aid. That’s what’s so great about living up here in Wilmington.”

Born-and-bred locals, Holzer and Gillilland have deep familial roots within their respective towns. Holzer’s great-great-great-great-grandfather was town supervisor in the 1800s. By age eighteen, Holzer had started a local newspaper and won election to the Wilmington town board. He and his wife owned and operated a small grocery for twenty-two years, which they recently sold to Holzer’s nephew rather than to a corporate chain. Gillilland’s roots run even deeper. The Gillillands still own a farm on a road bearing the family name, and Shaun’s ancestors literally settled the town: The “Will” from which “Willsboro” is derived is from its first European settler, William Gilliland (his name spelled with one fewer l), who arrived in 1765. His portrait adorns the town hall’s main room, site of local court hearings and town council meetings.

Emergency services are a concern for Holzer and Gillilland, but their situations differ somewhat because of their two towns’ proximity to vital healthcare services. In October 2022, Adirondack Health announced that it wanted to close its Lake Placid Memorial Hospital emergency room, which had already scaled back to half-day operations. Holzer was understandably panicked about what this decision would mean for his constituents. “I’ve been leading the charge on this because it really pisses me off,” he said. Holzer rejects Adirondack Health’s claims that the ER is losing money. He even cornered New York State governor Kathy Hochul, two months before we sat with him, when she visited Lake Placid to attend the University Games. As a former EMT, Holzer knows that if LPMH closes its emergency room, ambulances and the area’s residents will be forced to drive either forty minutes west, to Saranac Lake; thirty minutes southeast, to Elizabethtown, home to a Champlain Valley Physicians Hospital satellite facility; or nearly an hour to reach CVPH’s regional hospital complex in Plattsburgh, in neighboring Clinton County. Gillilland’s constituents in Willsboro, by contrast, are fortunate to live closer to the Elizabethtown and Plattsburgh facilities. (CVPH is not even a New York chain; it’s owned and operated by the University of Vermont system, based in Burlington, across Lake Champlain.)

However close their constituents live to the nearest hospital, both Holzer and Gillilland are dealing with the problem of retaining qualified emergency services personnel. The two towns have long relied upon volunteers, but the number of volunteers is shrinking and aging out. “You can’t have a bunch of seventy-five-year-olds doing it,” Gillilland said with a shrug. But Essex County simply cannot afford the millions it would take to hire an all-professional, full-time EMT staff. So it applied for and won a six-million-dollar grant from New York State to implement a transitional pilot program, focused initially on four of the county’s eighteen towns. (Wilmington is one of the four; Willsboro is not.) When money from that short-term grant expires, Essex will implement a shared-funding model wherein the county will cover the cost of emergency medical technicians’ benefits (pension contributions, healthcare premiums), but each of Essex County’s towns will cover the hourly wages of the EMTs when they work in their town. “It’s a helluva lot cheaper than hiring a full-time employee,” Gillilland explained.

Rural leaders across the United States grapple with many of the same problems that Supervisors Roy Holzer and Shaun Gillilland do—from finding creative fiscal solutions to maintaining quality facilities and services. More than half of rural hospitals nationwide currently operate in the red, and hundreds more have closed entirely. A single emergency room closure, or the inability of ambulatory services to quickly retrieve and deliver citizens to an ER, can have life-or-death consequences. Even in rural places blessed with assets other rural towns envy (like Wilmington and Willsboro), battling public and private entities to maintain vital services is commonplace.

Think tanks, advocacy groups, and government agencies have issued countless reports on the devastation of rural America. Many of these studies pre-date Donald Trump’s presidential bid, which itself occasioned a new round of attention to rural crises from public officials and the media. A variety of painful and sometimes lethal socioeconomic problems now confronts the nation’s small towns and counties: shrinking populations, economic distress, crumbling infrastructure, and an epidemic of “deaths of despair” from gun suicides and opioid overdoses.

In this chapter, we chronicle the problems confronting contemporary rural America. The economic and health-related struggles that rural Americans face matter directly but also indirectly, because the decline of so many rural communities has caused many rural Whites to question whether the U.S. political system properly and sufficiently serves them.

Stagnant Populations

Let’s begin with population decline. The population in rural areas is either shrinking or growing at a far slower rate than that of the rest of the nation. At just 7.4 percent, population growth in the United States during the 2010s was the slowest of any decade since the 1930s. But growth was not uniform: Urban and suburban areas gained a net of 21 million people, while rural areas shrank by 226,000 people.The five states with the largest declines in nonmetropolitan populations during the 2010s were, in descending order, West Virginia, Illinois, Louisiana, Arkansas, and Pennsylvania.

Between 2010 and 2020, more than half of all U.S. counties, 53 percent, lost population. Because 81 percent of metro areas grew during that period, most of the shrinking counties were rural. In fact, two-thirds of rural counties—1,326 in all—lost population over the last decade. Most of these population losses occurred in “persistently poor” rural counties that the U.S. Department of Agriculture classifies as having at least 20 percent of residents living persistently below the national poverty level since 1980.

Six decades ago, the term white flight entered the American political lexicon. In response to racial integration, urban Whites fled to the suburbs in search of more land, bigger houses, and lower taxes, and to re-create the urban White communities that existed before the Great Migration brought millions of African Americans northward. Today, white flight takes a new form and direction: Hundreds of thousands of rural Whites are relocating to more diverse and densely populated suburbs and cities. In fact, 42 percent of rural residents report knowing somebody who has recently moved away from their community.

Young Americans are abandoning rural areas, draining rural America of its most precious asset: its future. In 2010, sociologists Patrick Carr and Maria Kefalas published Hollowing Out the Middle: The Rural Brain Drain and What It Means for America. They interviewed hundreds of people in a small, rural Iowa town and found that rural parents and schoolteachers invest unusual resources in their most promising teenagers, the ones most likely to get into good colleges and never return home. “Fueling the out-migration is a regional filtering system pushing some young people to stay and others to go,” Carr and Kefalas concluded. “Teachers, parents, and other influential adults cherry-pick the young people destined to leave and ignore the ones most likely to stay or return.”

A national survey conducted by the University of New Hampshire in 2018 revealed that 61 percent of nonmetro adult respondents said they would “advise teens to move away.” Only 40 percent of metro adults say the same. Nobody can blame self-interested parents and teachers for urging their best and brightest youngsters to seek more promising futures, even if that means exporting rural America’s best human resources to cities. “When one considers the blighted and aging nature of many American towns, it’s obvious that there are no easy solutions ahead,” writes Gracy Olmstead, an Idaho journalist and author of Uprooted: Recovering the Legacy of the Places We Left Behind. “But one thing is certain: Unless we can begin convincing some of these young people to stay, to move in, or to move back, we won’t get the chance to find those solutions.”

We heard similar stories during our travels. Mila Besich shared her experience as a high school senior in Superior, Arizona, the small, majority-Latino rural city in the state’s so-called Copper Corridor region, over which she now presides as the city’s mayor. “If you would have come to Superior a decade ago, everything was boarded up. When I graduated from high school, this town was blighted. It was in decay,” Besich told us. “My high school guidance counselor was like, ‘BHP [one of the mining companies that operates in the area] is shutting everything down. There’s not going to be any mining going on here at all. You guys are the top of your class. Get the hell out of here. We’ll get you as many scholarships as we can. There’s not going to be anything for you here.’ ”

A few hundred miles northeast, in Arizona’s Apache County, on Election Day 2022, Navajo Nation Council candidate Shawna Ann Claw talked to us while greeting voters on their way to cast ballots at her local polling place in Chinle. When we asked if brain drain was a problem on the reservation, she said, “Yes, it is. And I speak personally because I have a son and a daughter, and they both reside off the reservation.” Her son is in the U.S. Air Force, and her daughter lives in Phoenix. “She wants to open a business. She’s going to school for cosmetology. She sees the service industry is something that we don’t have here on the Navajo Nation [Reservation]. We don’t have a salon, we don’t have a barbershop.”

But Claw is sure her kids will return. “I really feel like they are rooted,” she said wistfully. “I have no doubt they’re going to return. And when my son returns, he’s going to just take my place here as a leader and guide his people. That’s how much faith I have. Because I was raised in a traditional way by my grandmother and my grandfather in a dirt floor hogan [a traditional Navajo log-and-mud dwelling]. So that commitment to service, to community, and family is very important for us.” Claw won her election from the Chinle Chapter and now holds one of twenty-four seats on the Navajo Council.

In Malone, a small city of about fifteen thousand people in Franklin County, New York, we asked town supervisor Andrea Stewart about the four kids she and her husband raised together. None still resides in the area, she told us. The common thread connecting the stories from Besich, Claw, and Stewart is that they are middle-class, educated local leaders. The children of less fortunate rural parents may also leave home, but surely they are less likely to have the encouragement and resources to do so.

Covid-19 caused enough Americans to rethink their living arrangements that demographers wondered if the pandemic might trigger a rural revitalization. Reporters filed stories about affluent retirees and remote-work professionals trading expensive urban condos for bucolic rural homes. But the effects of these new arrivals have been mixed. On the one hand, residential and commercial property sales raise values for existing homeowners and businesses, creating windfalls for local real estate agents, builders, and retailers. On the other hand, new arrivals rarely bring children to fill the empty seats of rural classrooms.

The same story repeats itself across the country: However much affection rural people have for their homes, they doubt that young people can build a prosperous future if they don’t leave. Across the United States, rural population declines have forced many communities to close and consolidate their school districts. But school consolidation is uniquely complicated for rural parents and communities for one simple reason: Their school-age kids live farther apart from one another than do students in more densely populated suburban and urban areas. Rural school consolidation thus forces students from closed facilities to travel long distances.

Upon becoming West Virginia’s new governor in January 2005, conservative Democrat Joe Manchin—who grew up in Farmington, a town of about eight hundred people when Manchin was a boy—immediately established guidelines to protect rural students from spending too much time on school buses. Manchin’s rules restricted the one-way bus commutes for elementary school children to no more than thirty minutes, forty-five minutes for middle-schoolers, and an hour for high school students

West Virginia’s Mingo County had no choice but to consolidate. Like so many rural counties, Mingo lost population over each of the past seven decades. Today, its roughly 23,000 residents represent half the number who lived there in 1950, when the county reached its peak population. (By comparison, the national population has more than doubled since 1950.) With plenty of empty seats in each of the county’s four high schools, the costs of staffing and maintaining all four facilities became too burdensome, and in 2014, Mingo County consolidated its high schools in Burch, Gilbert, Matewan, and Williamson, the county seat, into one. The new Mingo Central High School, formed from remnants of the four shuttered high schools, was constructed on a reclaimed surface mining site in Newtown. A town built on coal built its new high school atop a former coal mine.

To stem the tide of shrinking populations, rural leaders are getting creative. At least fifty rural communities across the United States have enacted programs designed to lure new residents with a mix of tax credits, housing subsidies, and other relocation incentives.The West Virginia Legislature is considering a bill that would provide up to $25,000 in tax credits to former residents willing to move back to the Mountaineer State. During the height of the pandemic, these efforts seemed to have an effect, if only temporarily: In 2021, rural areas made slight population gains of 0.13 percent—a small bump, but better than continued decline.

For most of the two-thirds of rural counties that have lost population since 2010, declines have been modest, typically under 3 percent. Majority-Black rural towns and counties have experienced above-average population losses.Still, except for select communities blessed with outdoor and recreational attractions, or a sudden economic boom caused by oil or fracking discoveries, most rural towns and counties are slowly but steadily losing residents as the rest of America continues to grow.

Economic Decay

What are rural Americans who abandon their hometowns leaving behind? The short answer is economic contraction and decay defined by declining wages, rising unemployment, persistent poverty, and increased government dependency.

Almost all rural problems are rooted in struggling local economies. Industries like farming and mining have suffered from a variety of assaults, both domestic and foreign, including but not limited to greater competition from global markets, corporate consolidation, the rising power of giant agribusiness, and a dramatic shift in the U.S. economy toward the healthcare, education, and service sector industries. Stagnant rural populations compound rural economic travails: More than a third of owners of rural small businesses say they cannot find enough qualified local employees.

In the two years following the 2008 Great Recession, unemployment surged across the United States, but during the 2010s, metro-area jobs eventually returned to pre-crisis levels. Nonmetro areas, however, never fully rebounded: Counties with populations of 100,000 people or fewer lost a net 175,000 jobs after 2008. Shockingly, there are fewer rural businesses today than there were before the recession began a decade and a half ago. Economic mobility in the United States is now lowest in the rural counties of the South and Midwest. This failure of rural areas to rebound post-recession contrasts sharply with the years 1992–96, when one-third of new small businesses formed after the 1991 recession opened in small counties.

Globalization certainly contributed to the collapse of rural economies. Politicians ranging from Republican president Donald Trump to former Ohio Democratic congressman Tim Ryan routinely blame emerging economies like China for stealing blue-collar American jobs that once paid well and included decent benefits. But for decades, Republicans promised that if workers surrendered their labor union advantages—better wages, healthcare coverage, and retirement benefits—U.S. companies would be able to compete. This was a lie: Union membership plunged over the past forty years, yet millions of industrial jobs vanished anyway.

These job losses have not dissuaded rural constituents from voting every two years to re-elect politicians promoting “right-to-work” laws that make it harder for unions to organize, even as those rural constituents struggle to survive on the meager wages and health benefits their nonunion jobs provide. It’s not because people are opposed to unions: In the summer of 2022, Gallup reported that support for unions had risen to 71 percent, the highest level since 1965. Yet Republican state legislators or members of Congress from rural, overwhelmingly White communities who support unions, a living wage, or universal healthcare are rare. Their opposition to paid sick leave is a perfect example of how rural voters elect politicians who vote against their material interests. “While a growing number of states, cities, and counties have passed paid sick leave or general paid time off laws in recent years, most states where more than 20% of the population is rural haven’t, leaving workers vulnerable,” reports Jazmin Orozco Rodriguez of Kaiser Health News. “Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.”

Didn’t bad trade deals negotiated by the federal government destroy rural America’s agricultural economy? That’s the narrative peddled by self-styled economic nationalists like Steve Bannon, who repeatedly blame the North American Free Trade Agreement and other trade deals for the existential crisis facing rural America. In almost every 2016 campaign speech, Donald Trump called NAFTA the worst trade agreement the United States ever negotiated. As president, he enacted new tariffs.

NAFTA, however, cannot be blamed for the steep drop in U.S. crop prices in the postwar period. Although crop prices rose 41 percent between 1945 and 1970, in relative terms, they shrank compared to the 116 percent increase in the price of consumer goods over that same period. The next two decades were worse: Between 1970 and 1990, the inflation-adjusted prices for wheat, soybeans, and corn cratered by two-thirds or more. Ratified by the United States, Canada, and Mexico in 1994, NAFTA obviously did not cause the steep plunge in agriculture prices during the five decades before it took effect.

Corporate consolidation at home exacerbates market pressures from abroad. Supposedly free-market politicians rarely admit that monopolies and oligopolies transformed the agricultural economy, making the family farm an endangered species. In 2018, the four largest meatpacking firms controlled 85 percent of the beef market. The four largest hog processors accounted for 70 percent of the pork market. Likewise, four firms held 85 percent of the market in corn seeds. In the United States, the number of large farms—those of one thousand acres or larger—doubled between 1978 and 2017. In 1940, 53 percent of rural Americans lived on farms, but now only 6 percent do.

The uncomfortable truth is that small family farms that once fed the nation and enriched local farmers were gobbled up by ConAgra, not China. To cite one notably sad example, 44 percent of small dairy farms in Vermont—a state that rivals Wisconsin in its cheese and dairy product production—have shut down just since 2012 Frustration is growing: In 2023, fifty activists met at the Rural Policy Action Summit in Omaha, Nebraska, to develop strategies to protect family farmers from agribusiness monopolies.Rural folks are gradually realizing that corporate consolidation, not socialism, is destroying their local economies.

Peanut farming in the Albemarle region of Eastern North Carolina typifies the transformation of rural agriculture. Northampton County is home to lumber companies Georgia-Pacific and Clary, plus a Lowe’s Home Improvement distribution warehouse. But the county—which not long ago led North Carolina in peanut production and ranked thirteenth nationally—has long depended upon peanut farming and still ranks fifth in the state in peanut production. In operation since 1945, Aunt Ruby’s Peanuts is the oldest retail business in Enfield, a small town with mostly boarded-up storefronts in neighboring majority-Black, rural Halifax County. Bob Allsbrook, the founder Ruby Allsbrook’s son, told us that like so many other agricultural commodities, peanut farming has become increasingly consolidated: Aunt Ruby’s now sources its peanuts from a smaller number of larger operations than it used to. “Small farmers, family farms, is a thing of the past,” Allsbrook lamented.

The rise of large agribusiness farming has also transformed rural partisanship. In their analysis of Great Plains farming, political scientists Aditya Dasgupta and Elena Ruiz Ramirez conclude that technological changes (especially center-pivot irrigation systems) accelerated the conversion of postwar Democratic-leaning rural communities into the Republican strongholds they are today. How? As Dasgupta and Ramirez explain, agribusiness lobbyists pushed legislators to link federal farm subsidies to total output, with large farms favored over family farmers. “Large-scale farms and agribusinesses have also sought over time to reshape the farm subsidy system, seeking to delink subsidies from production controls—the lynchpin of the New Deal–era farm policies—in favor of a ‘market-oriented’ regime linking subsidies to the quantity of a farm’s output, concentrating subsidies in the largest farms,” they conclude. Big Ag consolidated land and rural power by forging alliances with local and state Farm Bureau chapters to build a Republican coalition that wields power exceeding its numbers.

Environmental historian Curt Meine agrees. Rather than drive small farmers into the arms of the Democratic Party, Meine contends that Big Ag destroyed family farmers and empowered Republicans by exacerbating rural antagonisms. “Concentration fed and fueled the politics of resentment, entrenched corporate power, depopulated the landscape, and weakened the autonomy and agency of farmers, consumers, local governments, and communities,” Meine said in The New Yorker. “I think this is at the very heart of the rural-urban political divide.” According to a 2020 Family Farm Action poll, a stunning 81 percent of rural Americans would be more likely to support a candidate who believed that “a handful of corporate monopolies now run our entire food system” and who would impose “a moratorium on factory farms and corporate monopolies in food and agriculture.”Yet rural White voters continue to elect corporate-friendly Republican politicians. The glaring disconnect between the economic realities that farmers openly concede and their electoral behavior is perhaps the most puzzling feature of contemporary rural politics.

During his first term, President Barack Obama and his agriculture secretary, Tom Vilsack, pushed for major changes to the 1921 Packers and Stockyards Act, a law originally passed to protect small farmers and prevent agricultural consolidation. Beginning with the Reagan administration, conservative judges devoted to the Chicago School’s free-market theories had steadily destroyed the act’s antitrust protections. By the time of George W. Bush’s presidency, the federal agency tasked with enforcing antitrust regulations was “deliberately suppressing investigations and blocking penalties on companies violating the law,” reported Lina Khan in her investigation of how Big Ag got so big. (Khan was later appointed by Joe Biden to chair the Federal Trade Commission, where she became a regular target of Republican attacks for her efforts to push back on corporate consolidation.) When Obama and Vilsack in 2010 demanded that Congress revive the law’s antitrust protections, a bipartisan group of members—most with close ties to Big Ag trade associations like the National Cattlemen’s Beef Association, National Chicken Council, and National Meat Association—watered down the Obama administration’s attempts to limit the degree to which commodity markets could consolidate, an effort that might have leveled the playing field for small farmers.

In her study of rural resentment in Wisconsin, political scientist Katherine Cramer met local farmers who had been devastated by agribusiness domination and the predatory corporate practices crushing family farms. But Cramer found that these farmers were far angrier with urbanites, liberals, and Democrats than they were with conservative Republicans who raised gobs of Big Ag campaign cash rather than raise policy objections to consolidation.

Natural resource extraction, a core component of many rural economies, is also in decline. In 1985, there were 178,000 coal mining jobs in America. But the industry fell into steep decline—not, as Republicans told people, because of environmental regulations, but mostly due to automation and competition from natural gas and, eventually, renewables that are cleaner and cheaper than coal. What were people from rural coal states like Wyoming, West Virginia, and Pennsylvania left with? Fewer jobs, their previously beautiful landscapes scarred by mountaintop removal, and a bunch of empty promises.

Still, voters wanted politicians to keep lying to them about a coal revival that was always just the next “red wave” election away. In the 2016 presidential election, Hillary Clinton risked her candidacy when she told a CNN town hall that “we’re going to put a lot of coal miners and coal companies out of business.” Folks in coal country took this as proof that Clinton was hostile to them and their interests. Her quote was repeated endlessly to show what an out-of-touch elitist she was. But few people heard and fewer remember the rest of what she said: “And we’re going to make it clear that we don’t want to forget those people. Those people labored in those mines for generations, losing their health, often losing their lives to turn on our lights and power our factories. Now we’ve got to move away from coal and all the other fossil fuels, but I don’t want to move away from the people who did the best they could to produce the energy that we relied on.”

Contrast Clinton, and her candor, with Donald Trump, who went to West Virginia, put on a hard hat, and told the easiest of campaign lies: “For those miners, get ready because you’re going to be working your asses off,” he told a cheering crowd. But Trump didn’t revive the coal industry. In fact, he failed to stop its continuing decline. Only 50,000 coal jobs remained in the United States when he took office, and by the time his term ended, that number had fallen to 38,000—a 25 percent decline during his four years in office.

Did voters in coal country punish Trump for letting them down? No. In 2016, the two biggest coal-producing states, Wyoming and West Virginia, voted more heavily for him than any other state: They favored him by margins of 46 and 42 points, respectively. Four years later, they voted for him by margins of 43 and 39 points, that small decline mirroring exactly the three-point drop between 2016 and 2020 in the margins by which Trump lost the national popular vote.

For all that environmentalists have warned about the climate change effects of burning coal, in the end, coal’s demise is being driven by free-market capitalism more than anything else. And true to form, capitalism doesn’t care what it leaves behind when it departs; that’s the problem coal country faces. Given domestic and global market forces, Trump cannot be blamed for the continuing decline of coal or other U.S. mining sectors. It is fair, however, to blame him for making outlandish promises that neither he nor any other president could deliver.

What’s ironic about the transformation of rural economies is that most locals grasp the hard realities. In a 2017 survey conducted by The Washington Post and the Kaiser Family Foundation, rural voters who said their communities had not recovered from recent job losses were asked if they thought it would be better to bring back “the same types of jobs” recently lost or to “create jobs in new industries.” By a two-to-one margin, 61 percent to 30 percent, rural residents advocated for creating jobs in new employment sectors. In other words, a solid majority of rural citizens agrees with the economic solution that Hillary Clinton, not Donald Trump, promised those beleaguered West Virginia coal miners in 2016. Confirming what rural voters already knew to be true did not, however, help Clinton come Election Day.

University of Oregon historian Steven Beda explains that the steady conversion of extraction-based rural jobs into service sector employment wreaks more than economic havoc on rural communities. Transitioning, struggling rural economies also experience a “Walmart effect” that destroys the core identity upon which many rural communities were built. “The identity of rural communities used to be rooted in work. The signs at the entrances of their towns welcomed visitors to coal country or timber country. Towns named their high school mascots after the work that sustained them, like the Jordan Beetpickers [sic] in Utah or the Camas Papermakers in Washington,” writes Beda. “How do you communicate your communal identity when the work once at the center of that identity is gone, and calling the local high school football team the ‘Walmart Greeters’ simply doesn’t have the same ring to it?” Tectonic economic forces are decimating rural economies, but economic decline is having an even more nefarious impact: It is erasing rural identities.

Proximity Is Prosperity

Family farming and extractive resource economies in rural America are cratering, but one rural business sector is booming: discount retailers like Family Dollar and Dollar General, which sell off-brand goods at rock-bottom prices. Discount retailers pop up where economies turn down, so their arrival is no sign of revival. Quite the opposite, in fact. “They serve a part of the country that Walmart doesn’t serve directly,” Al Cross, director of the University of Kentucky’s Institute for Rural Journalism, told NPR. “You have to maybe drive twenty miles to get to a Walmart. You might only have to drive five miles to get to a Dollar General.”

You can see the discount economy when you traverse the rural, majority-Black counties of North Carolina’s Albemarle region. Scattered across Bertie, Edgecombe, Halifax, and Northampton counties are more Family Dollar and Dollar General stores than you can count. Of course, with so many of the main street storefronts shuttered in rural small towns like Enfield, Rich Square, Tarboro, and Windsor, the wares once peddled by local merchants must now be purchased from the same retail chains whose predatory business practices drove the mom-and-pop stores out of town in the first place.

Dollar stores make life for cash-strapped rural consumers a bit more affordable and convenient. But because they drive out local businesses, discount retailers cripple rural economies in two related ways. First, when mom-and-pop stores shutter, profits shift from local business owners to distant corporations. Second, dollar stores create so-called food deserts, where fresh fruits, vegetables, and meats are replaced with processed foods, in places where obesity and diabetes are common. And the share of rural Americans living within ten miles of a store selling fresh produce is dwindling. One study found that citizens from rural and low-income areas spend more than 5 percent of their food budgets at dollar stores—nearly 12 percent for rural Black households. Obesity rates in rural counties are one-sixth higher than in metropolitan areas.

Living near a discount retailer may be convenient, but it is often a sign of economic peril. The retailers all pay very low wages; in 2023, the U.S. Department of Labor singled out Dollar General as a “serial violator” of labor laws that protect workers. And of course, these chains react to the barest whiff of union organizing at one of their stores with all the fury of a nineteenth-century mining company. Hoping to keep local businesses from folding, a growing number of rural officials has joined forces to try to prevent dollar stores from opening in their communities. In rural Ebony, Virginia, a coalition of White and Black residents is fighting its town board’s narrow 3–2 vote to approve a new Dollar General franchise in its town that opponents say will destroy locally owned proprietors and blight the bucolic landscape.

Distance, not discounts, is even more critical to rural prosperity. Why? Because the closer and more connected a rural county is to a medium-size or large metro area, the better it performs across a range of measures, from educational attainment to high-wage jobs. For rural Americans, proximity to more thriving small cities or large urban areas is prosperity.

At the Bozeman, Montana–based think tank Headwaters Economics, researchers in 2009 compared the prosperity of rural communities in the western states with their proximity to metropolitan areas. They found that “isolated” rural counties without airport access lag behind “connected” rural counties that either are a shorter drive from city markets or can ship goods via local airports to those markets. “The ability of a community to create or retain jobs in manufacturing or service and professional industries is limited by distance and access to markets,” their report concluded. “These sectors are therefore least likely to be found in isolated counties, more likely to be in counties that are connected via airports, and most likely to exist in [rural areas within] metropolitan counties.”

Distance from their workplaces also matters to rural commuters. As rural industries shutter, residents are forced to commute longer distances for work. Some federal programs support rural transportation, but commuting requires most rural workers either to own or to have access to a car. Rural workers are uniquely dependent on their automobiles, explains Strong Towns reporter Aubrey Byron. “The pivotal question on job applications, ‘Do you have reliable means of transportation?’ may be one you overlook, but if you’re without a car in the country, the answer is a resounding, disqualifying ‘No,’ ” Byron writes. “Whether because of finance or circumstance, the situation of not having or being able to drive a car becomes a constant need to beg rides from friends and loved ones, many of whom have their own sizable commutes to attend to.”

Not surprisingly, rural Americans endure longer average daily commutes and spend more on automobiles, a higher share of which are used cars that may need more frequent repairs. Rural drivers inclined to save both the environment and gas money by purchasing electric vehicles are also hamstrung by the fact that large, sparsely populated states struggle to provide sufficient EV charging stations. Indeed, Upper Midwest and Plains states feature the fewest electric vehicles.

It’s important to understand that most people wouldn’t trade their rural lifestyles away. Bucolic rural spaces offer incomparable charms. Far from light-polluted cities, rural residents can gaze at the stars overhead on cloudless nights. Many pastoral areas are otherwise so quiet that symphonies of chirping crickets count as noise pollution. But peace and quiet can also be liabilities for rural citizens, who are more likely to suffer the detrimental effects of social isolation. That is, distance from one’s friends and neighbors matters too, because being too distant can be isolating. That isolation leads not only to loneliness but also to physical risks like higher rates of stroke and heart disease. For rural seniors, especially those who are immobile, social isolation can be debilitating: Roughly three in ten rural seniors report that most days, they do not see a single friend or family member. “One of the greatest strengths of rural America has always been the sense of community, but when that breaks, it breaks bad,” Alan Morgan, president of the National Rural Health Association, argues. “In an urban setting, you might have social services to fall back on, but that’s nonexistent in rural [areas].”

Distance to recreational attractions also matters because proximity to tourist-friendly outdoor areas can mitigate the economic challenges of the post-industrial and post-extraction U.S. economy, but only for those communities fortunate enough to be close to those attractions. The Adirondacks of Upstate New York and the rugged hills of Southern West Virginia are perfect examples of how the blessings of recreational resources give certain rural communities the opportunity to capitalize on their natural resource advantages.

Site of the “Miracle on Ice” U.S. men’s hockey title team in 1980, the Lake Placid region is blessed with stunning mountains and lakes that would draw hikers, skiers, and cyclists even if this quaint Adirondack town had not hosted the 1932 and 1980 Winter Olympic Games. But the Olympic facilities there—hockey rinks, ski jumps, toboggan and luge tracks—can be an added draw for both tourists and world-class competitors only if they are maintained. To that end, in recent years New York State has appropriated more than $500 million for the Olympic Regional Development Authority to upgrade these facilities. In nearby Saranac Lake, the state also spent $8.5 million in 2022 to upgrade the Adirondack Regional Airport (SLK) and nearly $7 million to upgrade the local civic center, including its new curling facility.

SLK airport is located in the township of Harrietstown, New York. Town supervisor Jordanna Mallach explained to us how SLK serves as an economic driver. The state-funded upgrades created short-term construction jobs directly and ongoing income indirectly for workers who staff the airport’s new café. Cape Air offers regular round-trip service from SLK to Boston and New York City. These routes are heavily subsidized by the federal government’s Essential Air Service program, making these flights more affordable for locals. But SLK also serves wealthy visitors who arrive via private charters or personal jets to gain quick access to lavish Adirondack vacation homes or exclusive resorts like Lake Placid Lodge or the Point, on Upper Saranac Lake. For local residents to reap the economic benefits of the natural environment, they need extensive involvement—and lots of money—from the state and federal governments.

Like Mallach, Willsboro’s Shaun Gillilland and Wilmington’s Roy Holzer benefit from the revenues that short-term visitors and owners of second homes bring to the Adirondacks. But seasonal residents often complicate local governance for these understaffed town supervisors. For example, visitors increasingly use Airbnb or other short-term rental platforms to book rooms and houses (rather than traditional, business-zoned hotels and motels) in many Adirondack residential areas. The towns and counties benefit from taxes levied on these short-term rentals, but renters sometimes create noise and generate nuisance complaints or fail to observe garbage and recycling policies. Tensions between the locals who reap the rental income and their neighbors who deal with the consequences inevitably ensue.

Gillilland and Holzer told us they are working to find ways to balance these trade-offs. For example, Holzer is developing a plan to cordon off a section of town where short-term rentals would be banned. Gillilland has similar issues to manage in Willsboro, a town of 1,900 year-round residents whose population swells to more than 5,000 during summers. Because the Willsboro Point peninsula juts out into Lake Champlain, Willsboro is blessed with more lakefront property than other lakeside municipalities. “Therefore, we generate a lot of building permits for residential second homes,” Gillilland says, noting that buyers hail not only from nearby northeastern states but also from as far away as Texas, California, and even France.

In Southern West Virginia, local governments and entrepreneurs are taking advantage of the rugged mountain terrain to lure off-road vehicle enthusiasts. Hatfield-McCoy Trails is a network of more than nine hundred miles of trails for use by all-terrain vehicles (ATVs), larger utility terrain vehicles (UTVs), off-road jeeps, and motorcycles. Trails are open sunrise to sunset every day of the year, and riders must have permits and adhere to strict safety standards, including mandated safety equipment for vehicles, drivers, and passengers.

The trail system has quickly emerged as a significant cottage industry that generates income for local merchants in lodging rentals, food and beverage receipts, and equipment sales. According to a report prepared by Marshall University for the Hatfield-McCoy Regional Recreation Authority, those economic impacts are substantial. Although many locals in West Virginia and border counties in Kentucky and Virginia use the trails, the annual report estimates that nonlocals spend an average of $535 more during their visits, generating $53.4 million in 2021 for the fourteen West Virginia counties (including the five that contain trail segments) that benefit from tourist spending.

Devil’s Backbone Adventure Resort in Matewan, Mingo County, is a perfect example of how off-road trail riders are infusing needed capital into Southern West Virginia. Perched on a hill at the entrance to Devil Anse Trail 59, the resort, which opened in 2019, was named in honor of Devil Anse Hatfield, patriarch of the family that waged war against its rivals, the McCoys. The sprawling facility offers modern cabins to rent, a great restaurant, and an outdoor swimming pool. The parking spots arrayed around the Tipple Tavern are reserved for ATVs and UTVs, and although we had to park our car elsewhere nearby, the food was worth the walk. The facility has a mini-mart that sells trail permits and maps, snacks, beverages including wine and beer, firewood, ice, and other supplies. We stopped in after dinner to grab a couple of ice-cream novelties and examined the pin-filled map showing visitors’ hometowns. Though it was not a scientific sample, we saw that an impressive number of Ohioans come to Matewan to ride the trails.

But the development around the Hatfield-McCoy Trails shows the challenges of creating a recreation-based revitalization. As we’ve seen in other places hoping to develop recreational resources, this attraction required investment from both the federal and state governments—in this case, to clean and update the trails. The hope that the trails would create thousands of jobs and be the key to replacing the departing coal industry in the area has not come to fruition; instead, the trails have created only a few hundred jobs, spread out over those fourteen counties. While every tourism dollar helps, the struggling people in Southern West Virginia will need a good deal more to bring their economy to where they want it to be.

Rural leaders not blessed with the recreational allure of the Adirondacks or the West Virginia mountains may not have to deal with the complications of visiting tourists. But most would happily endure a few added governing headaches in exchange for the economic windfall tourists bring. The alternative—not having a natural resource upon which to capitalize—is far worse.

A familiar small-town boast is that rural folks know their neighbors by name and can leave their front doors unlocked—advantages that anonymous urbanites packed into high-rise apartments and condo buildings can only imagine. This is true. Rural communities closely connected to recreational hubs can enjoy quaint rural spaces and still prosper. That’s proximity’s upside.

On the other extreme is isolation. The proliferation of economic deserts dotted by discount retail stores, when coupled with rising social isolation, can turn rural communities into cultural deserts. If interacting with one’s neighbors is reduced to a weekly church service or the chance encounter at the local dollar store, rural American lives and livelihoods become diminished.

The Public Revenue Squeeze

Declining populations and withering economies pose another problem for rural communities: how to generate sufficient tax revenues to fund local governance.

For starters, the taxes generated from rising farm values provide local officials with short-term budgetary relief at best. A 2020 study conducted by agricultural economist Larry DeBoer found that since 2002, rural population losses in Indiana did not initially deplete local tax revenues because rising farmland values offset the losses from shrinking populations—at least in the short term. “Costs per person go up when rural populations fall, but the farmland remains to be taxed, and we increased farmland assessments a lot in the past 20 years,” DeBoer writes. “But as those people move to cities and urban areas, they increase costs in those places without doing as much for expanding the tax base.”

The ability to fund local priorities through taxes on farmland or extractive industries—rather than from property, income, or sales taxes levied directly on residents—is what public finance experts call “tax substitution.” As substitution options dwindle, rural leaders face three unpleasant fiscal options.

The first option is to double down by raising tax rates on extractive industries. Given the changing nature of rural economies, this option may be untenable. A 2020 report issued by the Center for American Progress (CAP) warns that rural governments long reliant on taxes levied upon resource-based commodities, ranging from corn to coal, must adapt to new fiscal realities. “Although agriculture, manufacturing, and mining have been the mainstays of the rural economy, due to increasing concentration of industries creating firms with extreme market power, this is no longer the case,” CAP policy analysts Olugbenga Ajilore and Caius Z. Willingham write. “In fact, the largest sector in rural communities in terms of employment is the service sector, specifically in health, education, and social services.” Local leaders can squeeze only so many tax dollars from the farms and mines that traditionally financed rural prerogatives.

The second option is to raise taxes on residents. Given rural voters’ stagnant incomes and resistance to higher taxes, this choice is electorally risky. It is also fiscally treacherous because higher property or income taxes may encourage longtime locals to leave and may deter potential newcomers from buying rural retirement or vacation homes. Even if rural officials wanted to target residential property tax hikes to wealthy carpetbaggers, they would run afoul of the statewide tax limits that followed the tax revolts led by conservative Republicans like Ronald Reagan that began in the late 1970s. “Resource-dependent communities are not blind to the dilemma of reliance on fossil fuel, timber, and mining revenue to pay the bills. But they remain trapped by it because of fiscal policy crafted at state and federal levels,” a Headwaters Economics think tank report concludes. “It is easier for Wyoming community leaders to protect the fossil-fuel industry from climate policy or public land protection…than to ask their constituents to raise taxes on themselves. These dynamics are not lost on politicians seeking to remain in office.” Superior, Arizona, mayor Mila Besich told us her county tried to pass a local tax increase, but the Goldwater Institute, the Phoenix-based anti-tax think tank, helped block the measure.

This leaves the third and perhaps most painful option, even if it makes the most sense given stagnant or declining rural populations: cut spending and reduce public services. Many local governments have chosen to reduce or eliminate spending on municipal projects and programs, hoping state or federal officials can somehow offset these losses. State and federal governments often step in, which is why rural Americans increasingly depend on a variety of targeted welfare programs, subsidies, and tax benefits.

Polls repeatedly confirm that many rural Whites believe federal policies favor minorities living in cities. This is a comforting delusion. The truth about federal largesse is obvious to anyone who spends even a few minutes on the U.S. Department of Agriculture’s rural development homepage, which lists seventy programs focused exclusively on rural communities. These programs include loans, grants, subsidies, or training resources for individuals, businesses, agencies, and local governments to support housing, healthcare, energy, small business development, agriculture, community facilities, infrastructure, water quality management, and sewage treatment.

Those are just programs at the USDA, a single cabinet-level agency. All told, twenty-three federal departments or agencies administer approximately four hundred rural-targeted programs. More than a dozen congressional committees are empowered to create programs that serve rural businesses or constituents. Then there are the various tax credits, available to the public at large, but upon which rural Americans increasingly rely.

For example, a rising share of rural citizens qualifies for either the Earned Income Tax Credit, the Child Tax Credit, or both. According to the American Community Survey five-year summary for the years 2014–18, the 17.9 percent of rural Americans (i.e., those from “non-core” counties) who receive Social Security disability payments is higher than the share of those living in either micropolitan counties (15.9 percent) or metropolitan counties (12.0 percent). Subsidized and welfare-dependent rural Americans are neither ignored nor neglected by the federal and state governments. Contrary to what many rural people believe, federal funds don’t flow disproportionately to cities. In fact, metro and nonmetro areas have traditionally received about the same amount of federal spending per capita.

Those streams of funding can make a difference on the ground. To take one example, the county court complex and police headquarters in rural, majority-Black Northampton County had deteriorated to the point where bats were living in the cupola of the courthouse building. But thanks to an infusion of funds from both the state and federal government, the county is completing a new governmental complex, slated to open in 2024.

Stories like Northampton’s illustrate an important point: Much of the time, when services are expected to improve and economic opportunity begins to arrive in rural areas, it’s because the government at higher levels stepped in to make it happen. Rural economies are under intense pressure, and local officials face budgetary squeezes. The collapse of rural economies has had many spillover effects, few of which are beneficial or welcome. Tough times are compounded by even tougher fiscal challenges.

Unhealthy Heartland

As go local economies and budgets, so go vital healthcare resources. When combined with a variety of poor lifestyle choices—some undoubtedly caused by their environment—the loss of health services and providers causes rural illness and premature deaths to surge. Rural America is increasingly sick and dying.

Healthcare facilities are disappearing from rural communities. In just the dozen years comprising 2010 through 2021, 136 rural hospitals either closed completely or became “converted closure sites” that no longer provided inpatient care. Because they serve older, sicker, and poorer populations that often lack insurance coverage, rural hospitals are less profitable, more fiscally vulnerable, and therefore at greater risk of closure. Physician shortages are also projected to hit rural communities harder than the nation overall. In rural America, a place where politicians routinely espouse support for the “pro-life” agenda, fewer than half of all hospitals offer labor and delivery services.

Rural hospitals that are part of statewide or regional chains are more likely than independent hospitals to remain open, but their survival is hardly guaranteed. One study found that for-profit chains sometimes close stable, if less profitable, rural hospitals purely as a “business decision that did not prioritize community needs.” Translation: Capitalism, not some nefarious socialist boogeyman, is shuttering rural hospitals.

When hospitals close, rural communities lose access not only to quality healthcare and emergency services but also to a vital employer and economic engine; in many rural places, the biggest employers are the school district and the nearest hospital. Given the high-quality jobs with good benefits that hospitals provide, rural hospital closures can devastate the surrounding community, according to a report issued by the University of North Carolina’s Cecil G. Sheps Center for Health Services Research. Healthcare access also affects the real estate choices of seniors, who are more likely to retire in rural communities that feature decent healthcare facilities. In conservative states especially, rural areas may well become less attractive to obstetric/gynecological doctors and others who provide family planning and pregnancy services in the wake of the Supreme Court’s 2022 Dobbs decision.

When your local hospital or clinic closes, it means you’ll need to travel even farther to get care. For general inpatient and emergency departments in rural areas, the median travel distance in the seven-year period between 2012 and 2018 rose sevenfold, from roughly 3.5 miles to about 24 miles. In the middle of the opioid crisis, the distance to reach an alcohol or drug treatment clinic increased eightfold, from 5.5 miles to 44.6 miles.Compounded by weaker cell phone service, dangerous driving conditions, and lower seatbelt use in rural communities, the extended distances that ambulances must drive to retrieve rural car accident victims and deliver them to emergency rooms are why nearly half of all car crash fatalities in the United States occur on rural roadways.

Rural pharmacies are vanishing, too. Between 2003 and 2018, one-sixth of independent rural pharmacies closed. Closure rates eventually slowed, but a 2017 study by the Center for Rural Health Policy Analysis of the Rural Policy Research Institute identified a series of connected problems that make prescriptions unaffordable for rural citizens.One in eight Americans—and majorities in 40 percent of U.S. counties, most of them rural—must drive at least fifteen minutes to reach a pharmacy.

As The Washington Post’s Markian Hawryluk explains, rural pharmacies are disappearing for the same reason local grocers did: “Independent pharmacies are struggling due to the vertical integration among drugstore chains, insurance companies and pharmaceutical benefit managers, which gives those companies market power that community drugstores can’t match.” In other words, giant pharmacy chains have devoured the little guys. Yet again, unfettered capitalism is making life more difficult for rural residents.

Despite national trends, we encountered some notable success stories. Thanks to two million dollars in federal aid secured by Democratic senator Joe Manchin, Williamson Memorial Hospital in Mingo County, West Virginia, is slated to reopen after being closed since the middle of the coronavirus pandemic in 2020. In rural Eastern North Carolina, the locally owned Futrell Pharmacy chain has kept open all four of its branches—two in Northampton County and one each in Halifax and Warren counties. In the five Texas Hill Country counties it serves, regional healthcare provider Baylor Scott and White Health has kept open all ten of its family medicine facilities, including the medical center, seven local clinics, and two specialty facilities. And in New York, the Citizens Advocates chain supervises developmental disability, mental health, and substance abuse facilities across five rural counties in the Adirondacks.

Even as medical facilities in rural areas depend on support from the federal government, especially through Medicare and Medicaid, rural resistance to expanded federal government–provided health remains a cause of declining health outcomes for rural Americans. If that claim sounds hyperbolic, read Jonathan Metzl’s book Dying of Whiteness: How the Politics of Racial Resentment Is Killing America’s Heartland. In the book, Metzl shares his encounter with Trevor, a forty-one-year-old former cabbie living in a low-income housing complex outside Nashville. When his years of hard partying and a hepatitis C infection caught up with him, Trevor could no longer work. By the time Metzl found him, his complexion was yellow with jaundice and he needed the help of an aluminum walker.

Metzl asked Trevor if he was upset that state Republicans had blocked implementation of the Affordable Care Act in Tennessee. Nope. “Ain’t no way I would ever support Obamacare or sign up for it,” Trevor said. “We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.” Never mind that, unemployed and disabled, Trevor almost certainly drained more from public coffers than he ever contributed in state or federal taxes. Nor would any of his tax dollars be spent on Mexicans. What mattered most to Trevor was his willingness, literally, to die in defense of his reflexive hatred of big government and socialized medicine.

At least Trevor’s resistance was a principled, conservative policy objection to Obamacare, right? Not likely. Repeated polling by the Kaiser Family Foundation shows that when asked about various national healthcare policies, Republicans support almost every one of the ten major provisions of the Affordable Care Act, often by solid margins. (The individual mandate provision is an exception.) Only when asked if they backed “Obamacare” did GOP support evaporate. Even White Democrats are less likely to support healthcare reforms when told that Obama was connected to these policies. In the years following the Obamacare debate, multiple studies showed that racial resentments drove opposition to the ACA even when factors like party identification and political ideology are held constant. White voters’ knee-jerk opposition to Obamacare was always more about the “Obama” part than the “care” part.

How did millions of people come to hate a law despite approving nearly every major provision in it? The short answer is that Republican politicians railed against Obamacare, vowing repeatedly to “repeal and replace” it. These incessant attacks created hatred among White Americans toward healthcare policies they actually support and from which they stood to benefit. Though hardly perfect, the Affordable Care Act offered numerous protections, guarantees, and options for citizens like Trevor in need of insurance. In fact, Obamacare led to two very profound changes in U.S. health insurance coverage that benefit rural communities.

First, as with Medicare and Medicaid, the law decouples insurance coverage from employment status. Decoupling reduces what economists call “job lock,” thereby giving workers greater flexibility to seek new opportunities: change careers, retrain themselves, or even relocate to take a better-paying or more rewarding job without fear of losing their coverage. Because it liberates workers to pursue their own best interests in the labor marketplace, Obamacare is quite the opposite of socialism. And who suffers most from job lock? Surprise, surprise: Rural Americans do, as they have fewer employment options than people who live in more densely populated areas.

Second, the ACA significantly reduced the share of uninsured rural citizens. In fact, rural uninsured rates for non-seniors fell from 24 percent to 16 percent in just nine years following passage of the Affordable Care Act. But the effects diverge between urban and rural areas because so many rural Republican states in the Southeast and Plains regions rejected the ACA’s Medicaid expansion provision, thus denying their most vulnerable citizens the opportunity to acquire health insurance. Some of the very same rural voters who fumed about Obamacare were prevented from benefiting from the law only by the Republicans they elected.

The fight over expanding Medicaid was of particular importance to rural America, where uninsured rates are high and medical facilities rely heavily on Medicaid funds to stay open. Until the passage of the Affordable Care Act in 2010, the cost of covering low-income Americans was split evenly between the federal government and the states. Each state was allowed to set its own eligibility criteria, and in practice, conservative states—most of which have large rural populations—were unusually stingy with Medicaid, such that a family had to be desperately poor to qualify. The ACA changed this by setting a single and more generous standard for eligibility.

But the conservative majority on the U.S. Supreme Court ruled in 2012 that states could refuse the expansion if they wished, and many Republican-run states did just that, even though under the law, the federal government would pay 100 percent of the cost of newly eligible recipients, a percentage that declined to 90 over the course of a few years. It was an extraordinarily good deal for states: They’d get a healthier population, an improved economy, and a stabler healthcare system while paying only a fraction of the cost. But for multiple states, the opportunity to give the finger to Barack Obama outweighed all this. By 2023, there were only eleven resister states remaining; in a number of right-leaning states, the public defied the GOP-controlled legislature and passed referenda accepting the Medicaid expansion.

Rejecting the ACA’s Medicaid provision offers yet another example of rural White conservatives voting against their own material interests. Rural Whites, after all, are uninsured at higher rates than their urban White counterparts. Rural inequalities tend to be especially punitive for rural non-Whites, and health insurance coverage is no exception: Although 24 percent of rural citizens are non-White, they account for 44 percent of the rural uninsured.

Republican-controlled states’ rejection of Medicaid expansion is perhaps the most glaring example of self-inflicted healthcare policy failure. The effects on rural residents are painfully clear: The 11.8 percent rural uninsured rate in states that approved expanded federal Medicaid coverage is nearly half the 21.5 percent for rural folks in the states that rejected Medicaid expansion. Yet Mississippi governor Tate Reeves and Republican legislators in 2023 reiterated their opposition to Medicaid expansion, even though federal help would have mitigated the catastrophic healthcare impacts expected to be suffered by rural Mississippians. In his State of the State address, Reeves urged lawmakers not to “cave under the pressure of Democrats and their allies in the media who are pushing for the expansion of Obamacare, welfare, and socialized medicine.” The state had a $3.9 billion surplus, which Reeves said should be used for tax cuts, including eliminating the state’s income tax. Just a few months earlier, the state’s health administrator had warned that as many as 54 percent of Mississippi’s rural hospitals may close. In rural America, a place where half of all hospitals now operate in the red, the share of money-losing hospitals in states that refused to expand Medicaid, 51 percent, is twelve points higher than the 39 percent in states that did.

Rural opposition to Obamacare and Medicaid expansion was the third and final act of a self-destructive political-electoral drama. First, rural Whites voted for national and state politicians who sided with the corporate interests that decimated their industries and healthcare infrastructure. Next, they rewarded those same politicians for opposing lifesaving and life-changing healthcare reforms. In the final and fatal act, many got sick, and some even died from lack of care or coverage.

Drug use and drug-related deaths are also decimating rural communities. Experts debate whether drug-related deaths in the United States surged because of a greater supply of potent opioids or because of deteriorating economic conditions. The effects differ between urban and rural Whites. According to public health expert Shannon Monnat, drug mortality rates among urban Whites are more closely linked to supply levels, whereas economic circumstances better predict per capita drug-related deaths for rural Whites. Of course, the combination of greater supply plus economic distress is especially lethal. “The highest drug mortality rates are disproportionately concentrated in economically-distressed mining and service sector dependent counties with high exposure to prescription opioids and fentanyl,” Monnat concludes.

Beth Macy’s chronicle of the opioid crisis, Dopesick, in part focuses on Virginia’s Lee County, one of many rural counties devastated by Purdue Pharma’s OxyContin. New Republic staff writer and Virginia native Sarah Jones draws a powerful parallel between the devastation that coal and drugs have had on coal miners in places like Southwest Virginia, West Virginia, and Western Pennsylvania. “Coal enriched its tycoons. Oxycontin enriched the Sacklers. Coal gave people work. Oxycontin allegedly gave them relief from pain,” Jones writes. “But while the coal industry extracted resources from the land and labor from the people who lived on the land, Purdue accomplished a particularly sinister feat. It extracted something essential from the people themselves: their will.”

We heard harrowing stories of how opioids destroyed so many lives in Mingo County, West Virginia. Mingo is the seventh-most lethal county in the most lethal state for opioid death rates, and its experience with drug addiction and overdose deaths is almost too tragic to fully comprehend. According to a 2018 congressional report, between 2008 and 2015, drug distributors sent more than 20 million doses of pain pills to Mingo’s county seat of Williamson, or about 6,500 doses for every man, woman, and child in the town.Residents told us about mile-long lines of cars stretching out from the pill mills, bearing license plates from all the surrounding states.

Guns also contribute significantly to rural death rates. This might come as a surprise to those who get their news from cable networks and talk radio, where conservative talking heads pretend to lament the scourge of urban violence. Here’s what those pundits rarely if ever tell their viewers and listeners: In 2020, the age-adjusted gun death rate in rural communities was 40 percent higher than that for large metropolitan areas. That same year, the murder rate in rural America surged 25 percent. Donald Trump was still president in 2020, yet somehow the same media that blame liberals and Joe Biden for urban crime never held Trump to account for the rural crime surge during his presidency.

In a detailed examination of the geography of gun violence, Politico Magazine’s Colin Woodard showed that gun death rates were lower per capita in New York City than in “red America” enclaves where Second Amendment advocates repeat “more guns equals less crime” talking points. Gun death rates vary widely among rural communities, too. “If you grew up in the coal mining region of eastern Pennsylvania your chance of dying of a gunshot is about half that if you grew up in the coalfields of West Virginia, three hundred miles to the southwest,” Woodard explains. “Someone living in the most rural counties of South Carolina is more than three times as likely to be killed by gunshot than someone living in the equally rural counties of New York’s Adirondacks or the impoverished rural counties facing Mexico across the lower reaches of the Rio Grande.”

Total gun deaths, of course, includes suicides. In 2021, more than half of U.S. gun deaths, 54 percent, were suicides. Unlike other forms of attempted suicide, gun suicides succeed 83 percent of the time. Nine out of every ten Americans who kill themselves with a gun are White.

And rural Whites are most likely to have access to guns and to die from gun suicides. Surging rural gun suicides are the result of higher gun ownership rates and lax gun control laws in rural red states. Polls show that 59 percent of rural Americans either own a gun or live in a home with a gun owner. Comparable rates are 40 percent in the suburbs and just 28 percent in cities.

To understand how much guns contribute to suicide rates, consider that suicide by all methods other than guns varies nationwide within a tight range, from a low among all fifty U.S. states of 4.6 suicides per 100,000 people in Mississippi to a high of 11.4 in South Dakota—a difference of just 6.8 percentage points. State gun suicide rates, by contrast, range from rural Wyoming’s 20.9 per 100,000 to most densely populated New Jersey’s 1.8—a whopping 19.1-point difference. In fact, the nation’s eighteen most rural states, those with at least 30 percent rural population shares statewide, all rank among the thirty states with the highest number of gun suicides per capita, including six of the seven highest, from Wyoming through West Virginia.

Non-rural residents in these states commit suicide, too. But gun culture is a lethal contributor to the higher suicide rates in rural states and communities. Second Amendment advocates love to say that “guns don’t kill people, people kill people.” In rural America, the more apt phrase might be, “Guns don’t kill people, but people with easy access to guns too often kill themselves.”

Like guns, abortion is a powerful culture war issue in rural America. Given that rural voters are Whiter, more evangelical, and more conservative, they are less likely to support abortion rights and reproductive health services for women seeking abortions. But the consequences of their opposition are often fatal, with rural communities suffering from both diminished access to pregnancy-related services and the highest rate of pregnancy-related deaths. Rural hostility to government-subsidized health insurance is also punitive for pregnant rural women, half of whom depend upon Medicaid for prenatal care.“The consequence of a lack of access to maternal care services, research shows, is that women living in rural areas often forgo prenatal, emergency and delivery care—which can have serious health consequences, such as severe hypertension and hemorrhaging,” write rural reporters Shelby Harris and Sarah Melotte of The Daily Yonder. There’s nothing “pro-life” about rural conservative leaders allowing pregnant rural women to give birth without healthcare coverage.

According to data reported by the CDC’s Pregnancy Mortality Surveillance System, pregnant women from rural areas are also far more likely to die during childbirth. Although outcomes vary from year to year, the roughly 26 deaths per 100,000 in rural or micropolitan areas is significantly higher than the approximately 16 women per 100,000 from urban areas who die giving birth. Maternal healthcare statistics in Texas are the worst in the nation; as one family doctor in West Texas said, “The lack of funding for rural healthcare—what we’re putting patients through because of this—to me, I think it’s unconscionable.” Fatality rates are higher for Black, Native American, and Asian American women than for Whites and Latinos. Like other rural crises, this problem seems to attract less public attention and media scrutiny because it disproportionately affects non-White rural women, who are tragic victims of their White neighbors’ policy choices.

According to a bombshell 2019 report by the Journal of the American Medical Association, for the first time in U.S. history the average lifespan for White citizens during non-wartime declined for three straight years beginning in 2014. This lethal pattern was especially prevalent in America’s smallest, most sparsely populated communities. In fact, fully one-third of all excess deaths during that three-year period came in just four states with significant rural White populations: Indiana, Kentucky, Ohio, and Pennsylvania.

These life expectancy declines occurred before the Covid-19 pandemic began. Disappearing health services and pervasive conspiracy theories about science and scientists set the stage for the next rural tragedy: heartland America’s disastrous response to the coronavirus pandemic.

Covid-19 did not hit rural America first, but it hit rural communities hardest. When the SARS-CoV2 virus arrived in the winter of 2020, urban areas suffered more because there were no vaccines and because most infected persons had arrived in the United States from abroad via airports in Boston, New York, Philadelphia, Seattle, and other major cities that are densely populated and more reliant on public transportation. Not surprisingly, for more than the first year of the pandemic, New York and New Jersey led the nation in per capita positivity rates and deaths.

By contrast, rural Americans enjoyed the geographic advantage of living in sparsely populated communities far from big-city airports. On March 17, 2020, President Trump tried to downplay Covid-19’s danger by noting that West Virginia, one of the nation’s Whitest rural states, had yet to report a single confirmed case.The president’s implicit message to his rural supporters was “Don’t worry, you’re safe.”

By December 2020, however, per capita fatality rates in rural areas caught up with urban rates. And the urban-rural disparity reversed dramatically after the Food and Drug Administration approved vaccines in January 2021. That summer, the lethal Delta variant of the virus arrived. By mid-2021, distance from major airports no longer conferred an advantage. What mattered most were vaccination rates.

As Americans lined up to be vaccinated in early 2021, higher shares of rural residents refused to receive the free, safe vaccines. The gap between rural and urban vaccination rates doubled from seven points in April 2021 (46 percent urban versus 39 percent rural) to sixteen points by January 2022 (75 percent versus 59 percent). Vaccine resistance also had a distinctly partisan pattern: Because rurality correlates highly with Trump support, the counties where Trump performed best tended to have the lowest countywide vaccination rates. Those lower vaccination rates in rural, Trump-loving areas inevitably translated into higher shares of rural residents testing positive, becoming hospitalized, and dying from the Delta variant.

In fact, per capita Delta cases were 2.4 times higher in rural counties than the national average and 3 to 4 times those of urban counties. And the less densely populated the county, the higher the per capita death rate. “During the first wave, the coronavirus death rate in the 10% of the country that lives in the most densely populated counties was more than nine times that of the death rate among the 10% of the population living in the least densely populated counties,” writes Bradley Jones of the Pew Research Center. “In each subsequent wave, however, the nation’s least dense counties have registered higher death rates than the most densely populated places.”

Monica Potts, a journalist who chronicles life in rural America, reviewed several studies that connect rural identity to vaccine skepticism. Rural citizens, Potts writes, tend to be more wary of science and “booksmart” experts at universities, preferring to trust their “gut” over the advice of such experts. Consequently, vaccine resistance became the latest manifestation of the skeptical rural mindset, preventing millions of rural folks from taking added precautions to guard against the virus. Perhaps most stunning, Potts found, the power of anti-science skepticism in rural communities even extended to rural physicians, who were more likely to question the validity and safety of the Covid-19 vaccine. “The vaccine-hesitant doctors shared many of the same characteristics as other vaccine skeptics: They were more likely to be rural and conservative,” Potts writes. “For rural areas especially, this data suggests a vicious feedback loop. People who were suspicious of the vaccines had doctors who were suspicious, too.”[119]

The 2021 Delta wave’s geographic effects were predictable and tragic. Despite a huge geographic head start, rural counties managed to match and then eclipse the death rates in urban counties; by mid-2022, in fact, the cumulative death rate of 401.9 per 100,000 people in rural areas was 37 percent higher than the 293.1 rate in urban areas. Most of these surplus rural deaths were avoidable. And West Virginia, the state Donald Trump boasted of being the last to have an official Covid-19 case? By May 2023, it ranked second nationally in per capita deaths, with 454 for every 100,000 citizens, barely behind Arizona’s rate of 456. Put simply, in just two years, West Virginia fell from first to worst.

Conspiracists claim that hospitals exaggerated Covid-19 death rates by counting persons who died with the virus as having died from it. Comorbidities contribute to Covid-19 fatalities, of course. But there is no evidence that hospitals lied about coronavirus-caused deaths. In fact, Covid-19 deaths were most likely undercounted, by some estimates as much as 36 percent. The most lethal co-morbidity—one never reported on a single death certificate—was the refusal to get a free, safe vaccine. The stubborn, conspiratorial-minded rejection of vaccine science was not confined to rural White communities, but it was most prevalent there.

Perhaps the most painful irony is that the rural White electorate, who voted for Donald Trump at even higher rates in 2020 than in 2016, were a specific target group for Joe Biden’s Covid-19 vaccine policy. After a year of President Trump peddling snake oil solutions like ivermectin and hydroxychloroquine, his successor’s vaccine campaign was almost certain to be greeted with skepticism by many rural citizens. Recognizing this obstacle, the Biden administration made rural communities a priority target for vaccines. Biden’s program deployed and funded faith-based groups and other organizations with rural credentials like the National Milk Producers Federation to persuade wary, misinformed rural voters to get vaccinated.

The excess coronavirus deaths in rural counties should be classified as suicides by scientific skepticism. By rejecting proven vaccines, conspiracy-addled rural Americans, though living in communities where social distancing was easier than in densely populated cities, squandered their geographic advantage.

All told, premature deaths from reduced healthcare access and facility closures, healthcare ignorance and scientific skepticism, and a fatal devotion to guns and drugs are killing rural White Americans—especially downscale rural Whites. In some cases, these problems are reaching epidemic levels and should concern every American, whatever their race and wherever they live.

Broke and Broken

Donald Trump won about five-sixths of all U.S. counties in the 2020 election, a statistic his supporters love to cite. Yet the one-sixth of counties Joe Biden carried produced an estimated 70 percent of the nation’s gross domestic product; the disproportionately rural Trump counties produced the remaining 30 percent. Four years earlier, the GDP split was 64–36 percent for Hillary Clinton–won counties. In 2000, the GDP tilt was only 56–44 percent for the counties Al Gore won. Counties with declining health metrics also swung significantly to Donald Trump in 2016. Blue counties are becoming more vibrant, healthier, and productive while red counties wither.

The economic and healthcare woes of rural Americans, and especially downscale White rural citizens, are real and consequential. In a piece about what he calls the “hard truths” of saving rural America, New York Times economics correspondent Eduardo Porter offers a powerful, if grim, summary of the malaise facing small towns and counties in the United States. “Rural America is getting old. The median age is 43, seven years older than city dwellers. Its productivity, defined as output per worker, is lower than urban America’s. Its families have lower incomes. And its share of the population is shrinking.”

So-called heartland America is embattled and beleaguered. Rural citizens are losing population, economic power, and other tangible signs of vitality, including a brain drain that is depleting communities of their most talented youth. They are becoming sicker and dying younger and often unnecessarily, sometimes by self-inflicted means. Some might be tempted to say this grim picture is entirely the fault of the people who live in these places, but the truth is far more complex. People make their own choices, but they can also be the victims of impersonal financial forces, amoral corporate profiteering, changing political realities, and the occasional global pandemic. What is beyond dispute is that with each passing year, the most deeply red, rural American places become more endangered. And there are few signs that rural decline will abate, no less reverse, anytime soon.