The hemorrhaging of Red America continues

[Previous: The lights are flickering in Red America]

Rural Americans are white, conservative, and Republican. That pattern holds overwhelmingly true, and it explains almost all of the political divide in America, even if some experts shy away from the implications.

I make no claims to be impartial about this. But if you can judge a political ideology by anything, you should judge it by the success or failure it produces. When that ideology gets to govern, do its followers thrive, or do they suffer? Do they have stable, prosperous, happy lives, or do they spiral down a vortex of misery?

Let’s consider a new piece of evidence summed up by this headline: “The urban-rural death divide is getting alarmingly wider for working-age Americans“.

As recently as 25 years ago, urban and rural areas had comparable death rates among working-age adults. But since that time, cities have been improving, while rural areas are faring worse and worse. A new report from the Department of Agriculture’s Economic Research Service shows just how wide the gap has gotten:

The report focused in on a key indicator of population health: mortality among prime working-age adults (people ages 25 to 54) and only their natural-cause mortality (NCM) rates — deaths among 100,000 residents from chronic and acute diseases — clearing away external causes of death, including suicides, drug overdoses, violence, and accidents. On this metric, rural areas saw dramatically worsening trends compared with urban populations.

…In 1999, the NCM rate in 25- to 54-year-olds in rural areas was 6 percent higher than the NCM rate of this age group in urban areas. In 2019, the gap had grown to a whopping 43 percent. In fact, prime working-age adults in rural areas was the only age group in the US that saw an increased NCM rate in this time period.

Rural areas have higher rates of drug overdose, suicide, alcoholism and other ills than cities, per capita. However, this conclusion holds true even if you exclude those causes and focus only on so-called natural deaths.

Your first thought might be that COVID accounts for a big chunk of the difference, but no. The researchers specifically excluded 2020 from their data set, because they considered it an outlier. However, including COVID would make this already huge gap into an even wider chasm, considering that the reddest parts of America had a COVID death rate almost six times higher than the blue ones.

There are no plagues that are unique to rural America. Red-state residents die from the same causes as residents of blue cities. They just die from them more often:

Among all rural working-age residents, the leading natural causes of death were cancer and heart disease — which was true among urban residents as well. But, in rural residents, these conditions had significantly higher mortality rates than what was seen in urban residents.

Why do rural residents die in larger numbers? A big part of the problem is that, because they’re more spread out to begin with, doctors and hospitals are few and far between. That makes it harder for them to get the medical care they need, both on a regular basis and in emergencies.

That problem is rapidly getting worse, because the health-care system in rural America is running on fumes. With each passing year, more and more rural hospitals are losing money, forcing them to pare back services or close entirely:

A recently released report from the health analytics and consulting firm Chartis paints a clear picture of the grim reality Ryerse and other small-hospital managers face. In its financial analysis, the firm concluded that half of rural hospitals lost money in the past year, up from 43% the previous year. It also identified 418 rural hospitals across the United States that are “vulnerable to closure.”

…According to Chartis, nearly a quarter of rural hospitals have closed their obstetrics units and 382 have stopped providing chemotherapy.

The harm inflicted by hospital closures goes beyond the sick people who are most directly affected. It tears holes in the social fabric. People with means won’t move to places where they can’t get medical care. Young people who want to start families will avoid places without labor and delivery wards. (Some rural states, like Idaho, are losing so many obstetrics wards that they may soon become maternity deserts in their entirety.)

When people don’t want to live in these places, employers will move away because they can’t attract talent. That creates a brain drain, worsening poverty and leading to a death spiral:

While people in rural America are more likely to die of cancer than people in urban areas, providing specialty cancer treatment also helps ensure that older adults can stay in their communities. Similarly, obstetrics care helps attract and keep young families.

Whittling services because of financial and staffing problems is causing “death by a thousand cuts,” said [Michael] Topchik [co-author of the Chartis study], adding that hospital leaders face choices between keeping the lights on, paying their staff, and serving their communities.

The article proposes, hopefully, that Congressional support will be needed to keep the lights on in rural hospitals. The brutal reality is that this isn’t going to happen, because there’s no constituency for it.

As the last few years have demonstrated, most voters living in these white rural enclaves don’t value their own health. More than that, they fight furiously against efforts to improve it. They’re loud supporters of Republicans whose only concern is punishing women for having abortions, or gay people getting married, or transgender people using bathrooms, or immigrants coming to this country to find jobs, or whatever culture-war noise Fox News is telling them to care about today. The politicians they elect do nothing tangible to improve their lives, and they seem content with that.

Meanwhile, the biggest policy proposals that would make a positive difference to rural voters’ lives – like the Medicaid expansion, or COVID vaccination programs, or infrastructure spending, or stronger unions, or even single-payer health care – are Democratic initiatives, and they resist all of them with furious tenacity. As long as they cling to these attitudes, their doctors will keep fleeing, their hospitals will keep closing, and they’ll keep getting sicker and living shorter lives. They’re literally dying of whiteness, and it seems that’s the way they prefer it.


  1. karl random says

    i’ve spoken with enough rural conservative types to know they are absolutely concerned about health, they just have different availability of information, and the lens thru which they interpret that information is hopelessly discolored by propaganda. like with the isolation of cults, contradictory info comes to support the narrative it contradicts, being easily twisted by supporters of the status quo. if one cares even about the lives of people they don’t like or get along with, this situation sucks giant balls.

  2. kenny256 says

    For Medicaid expansion, Alabama is a prime example. The great guv’nor Ivey proudly said that we not gonna take no money from the feds and have them telling us what to do.

    We gonna use our $2B surplus sales tax revenue to build more prisons.

    The republicons are proud to make everyone pay their own way for health insurance, even if they have no job or income below poverty–that’s the way god intended, says so in his book.

  3. kitcarm says

    I guess the rural county I live in is one of few exceptions. Our hospitals and clinics are always getting fully renovated or new ones are often opening. While we sadly vote Republican often, at least the ones we elect seem to be moderate and pro-healthcare. It probably helps that this rural county has a very large Hispanic population and more people from urban areas are moving in. The cynic in me often wonders if “we” (the county) are actually in support of such things or if the blue state I live in has more to do with it along with rural Democratic representatives located elsewhere within the state crafting legislation at the capitol. Either way, our local healthcare system is surprisingly robust so that’s all that matters in the end.

  4. anat says

    Rural areas, especially expansive ones like in the US, can only be revitalized under a very different economy – either we go back to being an agrarian society based on manual labor (not going to happen) or shift to working from home on an even larger scale than we had during the early phase of the COVID-19 pandemic. Otherwise, there aren’t jobs there. In which case we can think of most of rural US as a huge assisted living facility (plus its waiting list).

  5. kitcarm says

    I just remembered, there is at least one white majority rural county somewhere in Minnesota that still votes Democratic by good margins. Ditto in places in New England. I would love to see a sociological or anthropological study of such communities to see what makes them tick and still support human decency instead to turning to MAGA authoritarian politics.

  6. flex says

    @kitcam #5,

    I don’t know about all the places, but the farmers around my area always vote democratic because they remember the New Deal. In the early 1930’s, the Great Depression caused their crops to be worth less than it cost to grow them. In an attempt to raise crop prices, Hoover had the government purchase crops and store them. But Hoover’s policies couldn’t buy enough of the crops to keep farmers solvent. FDR’s New Deal paid farmers to not grow crops at all. You can buy a lot more scarcity by not creating a good than you can by stockpiling it. This kept crop prices high enough for farmers to stay out of bankruptcy. Which helped to maintain a stable food supply in the US. Which also helped to reduce discontent.

    It seems very contra-intuitive way to manage things. Paying people to not work in order to create enough scarcity to keep prices high enough to keep them from losing their farms. It’s a form of collective-planning but within a Keynesian economic framework. The policy has been lambasted as idiotic since it was introduced. But it worked.

    How well did it work? That’s hard to say. Because there were other tactics used by farmers against bankers who tried to dispossess farmers of their land for debts. Up to and including bankers and their hired agents being lynched.

    The reason these communities vote democratic is probably not because of superior human decency, but because four generations ago the democrats introduced a policy which allowed them to keep their family farm while the republicans were allowing bankers to foreclose on their debts. I’m a cynical old bastard, but I’ll wager that personal benefits outweigh human decency any day. And farmers have long memories.

    Not that these people voting democratic don’t support human decency. However, most republicans will also claim to support human decency. The two groups just have different definitions of both decency and fear.

  7. kitcarm says

    @flex. Interesting. This was the reasoning behind why some of the most Democratic-leaning rural counties in my state used to vote blue before going full MAGA. I now wonder why some places still remember this legacy and vote accordingly and why others just dropped it and changed course. A local news story I read once about those counties in my state said that the generations that remembered the New Deal and voted Democratic died off and the next generations of people changed course basically due to demographic and economic changes. If true, I’m very curious to why this phenomena hasn’t impacted several rural areas with seemingly identical conditions. Maybe I’ll research it and see if I can find answers.

  8. billseymour says

    kitcarm & flex:  I live in Missouri which is mostly rural.  It was once pretty blue; and St. Louis and Kansas City are still reliably Democratic; but the state’s other six congressional districts, including the 2nd district where I live (much of St. Louis County), is now full-on MAGA.

    It used to be that the 2nd district was lean-Republican and the 5th (Kansas City) was lean-Democratic; but in the last redistricting, my U.S. rep., Ann Wagner (for whom I’m not to blame, I promise), forced changes to make her district reliably MAGA and making the 5th reliably Democratic to compensate.

  9. flex says

    @kitcarm, (my apologies for the original typo),

    The semi-rural township I grew up in (and have moved back to) here in Michigan still has a number of farmers who remember their father’s memory of the New Deal. Most of them are in their 70’s now. Actually, up until recently one of them remembered the New Deal personally. He worked as an airplane engineer in the Willow Run plant during WWII, and died a few years ago at the age of 106. He was a character.

    The number of farmers in our township has been dwindling over the past 30 years, and the incoming landowners are invariably republican. The children of the old farmers in this township have not really been interested in farming, so while a lot of the old farmers are selling conservation easements, and often the land outright, to conservation groups in the area in an attempt to keep the township mainly rural, a lot of old farmland is being sold to private, rich, owners. We have some protection against major developments in the township’s master plan, and there is legal fund supported by a township miliage to fight developers who challenge the master plan. But unless we see a migration back to cities, our township is likely to end up as 5-10 acre lots for rich assholes who put up gates and leave yard lights on all night.

    If you are interested in researching why some rural communities haven’t switched to full-on MAGA, I’d start by looking at the property records of the landowners and look at their ages. The property records are public records and are usually available at the website of the local municipality, although you might need to figure out street addresses to look them up easily. I’d hazard that communities which haven’t switched are mostly inhabited by people in their 60s or older.

    There certainly could be another factor, but I’d start with age as it’s probably fairly easy to get objective data about that.

    FWIW, I was an elected official for 12 years in this township, so I do have some background in what’s going on here. I decided in 2020 to let people with more passion take my seat on the township board.

  10. flex says


    Any idea of how much of that was gerrymandering? I didn’t think to list that in my response to kitcarm.

  11. billseymour says

    Most of Missouri went through the shift that kitcarm was talking about.  The gerrymandering I mentioned was basically just the 2nd and 5th districts.  Ann Wagner wanted to protect her own seat because the Democrats put up a reasonable candidate in the last election; and in exchange she allowed the 5th district around Kansas City to move from lean-Dem. to reliable-Dem.

    Wagner’s not in the news much because she doesn’t do a whole lot of legislating.  She’s mostly just a money machine which makes her a major force in the Republican party, so she pretty much gets what she wants.

    And she’s a MAGAt.  From her website:

    The liberal mob will stop at nothing to seize power, and that includes silencing conservatives’ voices.  They’ve canceled books, movies, and even the President of the United States …

    It’s projection all the way down.

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