Variation in Health Care Resources in Rural and Urban Counties Associated with Differences in COVID-19 Mortality

Few studies have examined whether the variation of health care infrastructure and workforce had potential impacts on COVID-19 mortality in rural counties. Linking national datasets, we stratified 1,548 rural and 1,148 urban U.S. counties using 2021 COVID-19 median mortality rates (19.5 vs. 14.0 per 10,000 population, respectively) as a cut-point for high and low mortality to compare sociodemographics, vaccination status, access to health centers and hospitals, and health care workforce supply between and within rural and urban counties. High-mortality (compared with low-mortality) rural counties had a higher percentage of residents who were older, Black and/or Hispanic, less educated, in poverty, and uninsured. Among all county groupings, high-mortality rural counties had the lowest percentage of residents with a complete COVID-19 vaccination series, were least likely to have a hospital or virtual patient services, and had the fewest hospital-based personnel and population-adjusted advanced-practice registered nurses. Rural communities experiencing these health care gaps require targeted health policy and resources.