Nonmetropolitan America is home to roughly 46 million people spread across about 1,900 counties, and by nearly every major indicator of well-being it is diverging from the rest of the country. Between 2010 and 2020, nonmetropolitan areas lost population for the first time in recorded U.S. history, and the gap in mortality, income, broadband access, and health-care availability between metro and nonmetro counties has widened steadily since at least the 1990s. The term itself is a classification built by the federal government, but the lived reality behind it touches everything from how long an ambulance ride takes to whether a young person stays in the community where they grew up.
What “Nonmetropolitan” Actually Means
The U.S. Office of Management and Budget sorts every county in the country into metropolitan or nonmetropolitan status based on population size and commuting patterns. A metropolitan area centers on an urbanized core of at least 50,000 people and includes surrounding counties with strong commuting ties to that core. Everything else falls under the nonmetropolitan umbrella, which itself ranges from micropolitan areas (anchored by towns of 10,000 to 49,999) down to fully rural counties with no urban cluster at all. The classification gets updated after each decennial census, so a county can switch categories as its population shifts.
This binary split is convenient for policymakers but can hide enormous variation. A county on the exurban fringe of a major city may be classified the same way as a remote Great Plains county hundreds of miles from the nearest hospital. Research on U.S. poverty has shown that the simple metro/nonmetro distinction obscures important socioeconomic differences, and that layering in more nuanced rural-urban classifications reveals geographic complexities that the binary system misses entirely.1PubMed Central. Spatial variations in US poverty: beyond metropolitan and non-metropolitan When you see a statistic about “nonmetropolitan” America, keep in mind that it is averaging together places with very different circumstances.
A Shrinking Population, Then a Partial Rebound
For most of the twentieth century, nonmetro counties grew slowly or held steady. That changed dramatically in the 2010s. Between 2010 and 2020, nonmetropolitan America experienced its first outright population decline, driven by two forces working in tandem: fewer births relative to deaths (what demographers call natural decrease) and shifts in who was moving in and out.2Rural Sociology. Population Redistribution Trends in Nonmetropolitan America, 2010 to 2021 Many nonmetro counties now have more funerals than birth announcements in a given year, and without net in-migration to offset that, their populations shrink.
Migration remains the demographic lifeline. When people do move to nonmetro areas, the factors pulling them tend to be lower population density, proximity to natural amenities, and, in some periods, employment growth in certain industries. Research on metro-to-nonmetro migration has found that industry mix, distance to urban centers, and the share of older residents in a community all play into how attractive a nonmetro county is to potential newcomers.3American Journal of Agricultural Economics. Rural Bound: Determinants of Metro to Non-Metro Migration in the United States During the COVID-19 pandemic, some nonmetro areas saw a bump in arrivals from people who could suddenly work remotely, though whether that trend will stick remains an open question.
The Widening Mortality Gap
Perhaps the starkest way nonmetropolitan disadvantage shows up is in death rates. People living in nonmetro areas die younger, on average, than people in metro areas, and the gap has been growing for decades. A study tracking mortality from 1969 to 2009 found that death rates increased with each step toward greater rurality across racial and ethnic groups, and that metro residents experienced much larger mortality reductions over those four decades than nonmetro residents did, widening the divide.4PubMed Central. Widening rural-urban disparities in all-cause mortality and mortality from major causes of death in the USA, 1969-2009
More recent data shows the problem accelerating. Between 1999 and 2019, excess deaths attributable to living in a nonmetropolitan area climbed from roughly 8,400 per year to about 47,000 per year, accounting for around 9 percent of all nonmetro deaths by the end of that period.5PubMed Central. Evolution of the US nonmetropolitan mortality disadvantage by sex, state, and year, 1999-2019 The timing and severity vary considerably by state, but the overall direction is consistent: living in a nonmetro area carries a growing mortality penalty that shows no sign of reversing on its own.
The causes behind that gap are layered. Higher rates of smoking, obesity, and opioid use play a role, but so do structural factors like fewer physicians, longer distances to emergency care, and thinner social-safety-net infrastructure. It is not just that nonmetro residents are sicker on average; it is that the systems meant to keep people healthy and treat them when they are not are systematically weaker outside metro areas.
Hospital Closures and Emergency Care
Since 2010, well over a hundred rural hospitals across the U.S. have closed their doors. Each closure removes not just inpatient beds but often the only local emergency department, labor-and-delivery unit, and outpatient clinic in the area. A scoping review of the research on rural hospital closures found adverse effects rippling through multiple domains: emergency transport times, local economies, the availability of outpatient services, workforce stability, and quality of care.6PubMed Central. Understanding the impacts of rural hospital closures: A scoping review
The emergency-transport question is the one that most directly ties to life and death. When a hospital closes, how much longer does it take an ambulance to get a patient to an emergency department? The answer is not uniform. One study found that closures increased average ambulance transport times by about two and a half minutes and total activation time (from the 911 call to hospital arrival) by about seven minutes, though the effects varied widely depending on the patient and the specific closure.7PubMed Central. The effect of rural hospital closures on emergency medical service response and transport times A separate case-study analysis of five closures found even more variation: in one case, transport time jumped by thirteen minutes, while in two other cases it actually decreased, because patients had already been routinely transported past the closing hospital to a better-equipped facility.8Online Journal of Rural Nursing and Health Care. Factors Driving Rural Hospital Closures and Their Impact on Emergency Medical Care in Nonmetropolitan Areas
The takeaway is that a hospital closure does not automatically add thirty minutes to every ambulance trip, as the worst-case narratives sometimes imply. But it does, on average, add meaningful delays, and for conditions like stroke and heart attack where every minute matters, even a few extra minutes can shift outcomes. The closures also create a psychological toll: residents in communities that lose a hospital often report feeling abandoned and anxious about emergencies.
Behavioral Health in Short Supply
Mental health care is one of the sharpest points of the metro/nonmetro divide. Nonmetro counties have far fewer psychiatrists, psychologists, and other behavioral health providers per person than metro counties, and a higher share of nonmetro counties have no psychiatrist at all.9PubMed. Geographic Variation in the Supply of Selected Behavioral Health Providers This shortage is a problem in its own right and compounds others: substance use disorders, which have hit nonmetro areas hard (particularly opioid use), are difficult to treat when the nearest prescriber is an hour or more away.
Telehealth has been widely promoted as a partial fix, and it has expanded access for some people. But its effectiveness depends on broadband availability, which, as we will see, is itself unevenly distributed. A resident of a nonmetro county who lacks reliable internet cannot take advantage of a video therapy session, no matter how many providers are offering them.
The Broadband Gap
Internet access is the infrastructure issue that threads through almost every other nonmetropolitan challenge. You cannot do telehealth, remote work, or online education without a reliable connection, and nonmetro areas lag behind substantially. Data show that while about 82 percent of metropolitan households had broadband access, the figure dropped to around 74 percent for micropolitan areas and roughly 70 percent for small-town and isolated rural households.10PubMed. Geographic, racial/ethnic, and socioeconomic inequities in broadband access In isolated rural areas with high percentages of Black residents, broadband access dropped below 55 percent. Low access was geographically clustered in the Southeast, the Southwest, and the northern Great Plains.
The gap affects children directly. Rural school districts reported that only about two-thirds of their students had broadband access at home, compared with roughly 84 percent in urban districts.11PubMed Central. Disparities in Technology and Broadband Internet Access across Rurality: Implications for Health and Education Over three-quarters of rural districts said geography itself was a barrier, meaning broadband simply was not available in parts of their coverage area, compared with about 58 percent of urban districts. During the pandemic, when schooling moved online overnight, these numbers translated into children who could not attend class.
Poverty and education levels turned out to be the strongest predictors of whether a household had broadband, stronger even than simple metro/nonmetro classification. That means the broadband gap is partly a poverty gap, partly a geographic gap, and partly a legacy-infrastructure gap. Federal investment in rural broadband has increased since 2020, but the buildout is slow and expensive, especially in the low-density terrain where it is most needed.
Poverty, Inequality, and Persistent Disadvantage
Nonmetro poverty rates have historically been higher than metro rates, though the gap has fluctuated. During the 1990s, poverty rates in nonmetro counties actually declined faster than in metro counties, and the number of high-poverty nonmetro counties fell significantly.12Rural Sociology. The Changing Spatial Concentration of America’s Rural Poor Population That sounds like good news, and for some places it was. But the improvements were strikingly uneven by race. About half of all rural Black residents and a third of rural Hispanic residents still lived in poor counties. Among poor minorities, geographic concentration was even more extreme, and the number of nonmetro counties with persistently high child poverty remained above 600.
Federal economic development programs are supposed to help, but the mechanics of federal grants can work against the communities most in need. Many grants require a local financial match, meaning the county has to put up its own money alongside the federal dollars. Research across three Southern states found that the burden of those match requirements falls disproportionately on nonmetro counties.13Publius: The Journal of Federalism. Giving and Taking Away: Exploring Federal Grants’ Differential Burden on Metropolitan and Nonmetropolitan Regions The culprits were not metro/nonmetro status per se but the underlying wealth, land area, and fiscal distress of the counties in question. A poor, sparsely populated county may technically qualify for a grant but struggle to come up with the matching funds, effectively locking it out of the program.
Young Adults Leaving and What That Costs
One of the most familiar narratives about nonmetro America is the “brain drain,” where young, educated people leave for metro areas and do not come back. The pattern is real: expected gains in starting earnings give young workers a strong financial incentive to leave their nonmetro counties of origin, partly because the returns on education are higher in metro areas.14American Journal of Agricultural Economics. The Migration of Young Adults from Non-Metropolitan Counties When the people most likely to start businesses, fill professional roles, and pay local taxes leave in their twenties, the community’s capacity erodes over time.
But research has complicated the simple brain-drain story. Studies of young people’s migration and education found that those who stayed in nonmetro areas attained the least education, as you might expect, but those who moved to nonmetro areas from elsewhere actually gained more education than the simple narrative would predict. Academic performance alone did not explain the link between migration and educational attainment; available educational institutions and enrollment opportunities mattered as well.15Rural Sociology. Migration Behaviors and Educational Attainment of Metro and Non‐Metro Youth In other words, the problem is not just that smart kids leave. It is that the places they leave often lack the institutional infrastructure to develop and retain talent in the first place. Fixing that requires investment in local colleges, vocational programs, and broadband, not just appeals to community loyalty.
Immigration as a Demographic Counterweight
Against the backdrop of natural population decline and young-adult out-migration, immigration has quietly become one of the few forces adding people to nonmetro communities. During the 1990s and 2000s, an influx of immigrants, the majority of Hispanic origin, arrived in many nonmetro areas, drawn largely by jobs in meatpacking, agriculture, and food processing. Researchers have argued that if managed well, immigration can provide a lifeline to places that are otherwise hollowing out.16The ANNALS of the American Academy of Political and Social Science. Can Immigration Save Small-Town America? Hispanic Boomtowns and the Uneasy Path to Renewal
The effects have been mixed. Some communities have experienced real revitalization: new businesses, fuller schools, repopulated neighborhoods. Analysis of these “new destination” communities found that despite challenges like lower English-language proficiency and lower average educational attainment among newcomers, Latino influxes helped promote economic activity conducive to community engagement.17PubMed. Strangers in their hometown: Demographic change, revitalization and community engagement in new Latino destinations Other communities have experienced social friction, strained local services, and political backlash. The outcomes depend heavily on local leadership, the pace of change, and whether institutions like schools and health clinics adapt to serve a linguistically and culturally different population.
Housing Affordability in Nonmetro Areas
There is a widespread assumption that housing is cheap in nonmetro areas, and while it is generally less expensive than in major metros, affordability has been declining here, too. Between 1990 and 2016, housing affordability worsened across both rural and urban counties, but the mechanisms differed. In rural counties, population growth was associated with decreased affordability, while in large metro counties, population growth was actually associated with increased affordability through estimated decreases in housing costs, likely because large metros build more densely and have more flexible housing stock.18Rural Sociology. The Changing Landscape of Affordable Housing in the Rural and Urban United States, 1990–2016 Interestingly, natural amenity development, which many assumed would drive up rural housing costs as scenic areas attract wealthy newcomers, was not significantly associated with changes in affordability at the county level.
For people already living in nonmetro areas on low incomes, the housing situation is complicated by a limited stock of rental units, aging homes with deferred maintenance, and fewer subsidized housing options. A mobile home is far more common in nonmetro counties than in metros, and while mobile homes provide affordable entry into homeownership, they depreciate in value rather than appreciating, which means they do not build wealth the way a conventional house might.
Food Access and the Desert Problem
Food deserts, areas where residents have limited access to affordable and nutritious food, are disproportionately found in nonmetro counties. The combination of low population density, long distances, and thin profit margins makes it hard for full-service grocery stores to survive. When a small-town grocery closes, residents may need to drive thirty minutes or more for fresh produce, which hits hardest for elderly residents without reliable transportation and for low-income families without a car.
Efforts to fix the problem have had uneven results. A study of 71 planned supermarket interventions in food deserts found that management model mattered enormously: none of the nonprofit or community-driven stores had closed, while nearly half of commercially driven interventions and a third of government-driven ones resulted in canceled plans or closed stores.19Journal of Public Affairs. If you Build it with them, they will come: What makes a supermarket intervention successful in a food desert? Community ownership and engagement, in other words, was the strongest predictor of survival. A grocery store dropped into a food desert by an outside entity tends to fail; one built with the community tends to last.
Getting Around Without a Car
Public transit barely exists in most nonmetro areas. If you can drive, this is an inconvenience. If you cannot, because of age, disability, poverty, or a suspended license, it can be isolating in a way that is hard for metro residents to appreciate. Research on older nonmetro residents found that people aged 65 to 74 almost universally drove themselves, but those 75 and older, many of whom had stopped driving, had to cobble together rides from a patchwork of family, neighbors, volunteer programs, and the occasional public bus.20Journal of Applied Gerontology. Older Nonmetropolitan Residents’ Evaluations of Their Transportation Arrangements
As the nonmetro population skews older, this problem will grow. The loss of a driver’s license in a place without transit options can effectively cut off access to medical appointments, grocery shopping, and social contact. Some communities have responded with volunteer driver networks and demand-responsive transit services, but funding is perennially thin, and the distances involved make per-trip costs high.
Aging in Place and Long-Term Care
The aging of nonmetro America is not a future concern; it is already well underway. Nonmetro counties tend to have a higher median age than metro counties, partly because younger adults leave and partly because retirees move in. When older residents need long-term care, the options are often limited. Research on Medicare beneficiaries has found persistent rural-urban differences in how people receive long-term services and supports, with rural residents less likely to use home- and community-based services that would let them stay in their own homes. Federal and state efforts to build capacity in these programs may be necessary to close the gap.21PubMed. Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas
The alternative, institutional care in a nursing home, is both expensive and often located far from the person’s community. A nonmetro resident placed in a nursing facility in a distant town loses the social connections that can make a significant difference in quality of life. The policy challenge is to build enough home-care infrastructure in low-density areas to give people a real alternative, but hiring home health aides in places where the labor pool is already thin and wages are low is a hard problem without obvious solutions beyond sustained public investment.
How the Classification Itself Shapes Policy
One underappreciated aspect of the metropolitan/nonmetropolitan divide is how the classification feeds back into resource allocation. Federal funding formulas, eligibility criteria for grants, and regulatory requirements often use metro status as a variable. A county that gets reclassified from nonmetro to metro after a census update may suddenly lose eligibility for rural development programs, even if its residents’ circumstances have not meaningfully changed. Conversely, a county that remains nonmetro may benefit from targeted programs but also face the match-burden problem described earlier, where grant requirements assume a fiscal capacity the county does not have.
The classification also shapes how researchers and journalists think about these places. When you draw a single line between “metro” and “nonmetro,” you create two bins that each contain enormous internal variation. A struggling Appalachian county and a booming exurban county on the edge of a growing metro may both be classified as nonmetropolitan, but their needs, resources, and trajectories have almost nothing in common. More granular classification systems exist and are used in academic research, but policymaking still leans heavily on the binary. Until that changes, the label “nonmetropolitan” will continue to function as a blunt instrument applied to a complicated landscape.