It’s common knowledge that Americans living in rural areas have poorer health outcomes than their urban counterparts. But, despite policy efforts to ameliorate disparities, the gap is not getting any better, according to several new studies published in Health Affairs this week.

Rural residents have a 23% higher mortality rate, according to one of the studies, along with more preventable hospitalizations and emergency room visits. Rural outcomes are especially dire for chronic and behavioral health, with deaths related to chronic obstructive pulmonary disease, diabetes and suicide exponentially increasing over the past few years.

But despite the statistics, the population, which is also more likely to be low-income and with high-cost chronic conditions, is experiencing a paucity of care.

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CMS has tried to address the higher mortality rate through several recent initiatives, like expanding Medicare reimbursement for virtual care visits, allowing non-physician providers to offer some key primary care services and increasing the wage index of rural hospitals, allowing the facilities to recruit more staff and invest in more resources.