2025 Indiana State Rural Health Report

Challenges, Innovations, and the Road Ahead

Executive Summary 

Indiana’s rural communities face deep and persistent health challenges shaped by geography, workforce shortages, infrastructure gaps, and socioeconomic inequities. While rural counties represent 70% of Indiana's land and 64 of its 92 counties, they account for just 28.8% of the state's population. These communities often experience lower income levels, limited access to healthcare services, and worse health outcomes compared to their urban counterparts.

This report presents a comprehensive analysis of the current state of rural health in Indiana, drawing from statewide and national datasets to assess social determinants of health, healthcare access, chronic disease burden, behavioral health, maternal and infant health, and telehealth infrastructure.

Despite these challenges, the report also highlights emerging innovations, such as Mobile Integrated Health programs, and strategic investments, like those made by Health First Indiana. Sustained funding, targeted workforce development, expanded broadband access, and community-driven partnerships are crucial to improving health equity across Indiana’s rural landscape.

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Introduction

Indiana’s identity is deeply rooted in its rural heritage, from agricultural productivity to the resilience of small towns. Yet while 64 of Indiana’s 92 counties are rural, only 28.8% of Hoosiers live in these areas. This contrast between geographic rurality and demographic concentration frames a complex healthcare landscape, one shaped by both strengths and systemic challenges.

Rural Indiana communities are disproportionately impacted by health disparities stemming from limited provider access, transportation barriers, lower income, and aging infrastructure. These areas report higher rates of premature mortality, smoking, obesity, and substance use disorders. Educational attainment and broadband access—key predictors of long-term health—also lag behind urban areas.

As rural hospitals close or reduce their services, the burden shifts to overextended emergency medical systems and families who must navigate significant travel distances for care. Many of Indiana’s rural counties are designated as Health Professional Shortage Areas (HPSAs), Mental Health Professional Shortage Areas (MHPSAs), and Maternity Care Deserts.

This report aims to assess the current state of rural health in Indiana, using the most recent available data to illuminate the drivers of disparities and to highlight promising models of innovation. By understanding the unique needs of rural communities, Indiana can better align its policies, funding, and infrastructure to serve all residents, regardless of their geographic location.

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Key Findings 

• Access Disparities: Rural residents experience longer commute times, fewer healthcare providers, and limited access to specialty care, including obstetric and mental health services.

• Workforce Shortages: Nearly half of Indiana’s rural counties are ambulance deserts, and many lack adequate numbers of primary care, behavioral health, and dental providers.

• Health Outcomes: Life expectancy is lower and chronic disease rates are higher in rural areas, with elevated mortality due to drug overdoses, cardiovascular disease, and motor vehicle accidents.

• Behavioral Health Crisis: Suicide and opioid overdose rates are significantly higher in rural Indiana, driven by isolation, stigma, and gaps in mental health infrastructure.

• Digital Divide: Telehealth holds promise, but inadequate broadband access in many rural counties limits its potential.

• Maternal Health Decline: Over half of rural hospitals have closed their obstetric units, leaving many women without local maternity care options.

 

Socio-Demographic Make-up of Rural Indiana and Health Disparities

Key Findings

• According to the U.S. Census Bureau, 28.8% of Indiana’s population lives in rural areas, although rural counties comprise 64 of the state’s 92 counties.
• The average household income in rural areas stands at $63,469, which is considerably lower than $71,530 for those living in urban settings.
• In Indiana, 32% of workers drive alone and commute for longer than 30 minutes, indicating transportation-related challenges,
• Rural counties experience higher premature age-adjusted mortality rates at 419.4 per 100,000, compared to 398.1 per 100,000 in urban counties.
• Drug overdose mortality is higher in rural Indiana (27.64 per 100,000) than in urban areas (25.92 per 100,000), reflecting ongoing substance use challenges.

Introduction

Indiana is often perceived as a rural state due to its extensive agricultural lands and small-town environments; however, its population distribution reveals a more complex narrative. The U.S. Census Bureau indicates that approximately 28.8% of Indiana's population resides in rural areas, while 71.2% live in urban settings.¹ Despite this urban majority, 64 of Indiana’s 92 counties^2,3 are primarily rural based on factors such as land use, population density, and rural-urban community areas. This distinction emphasizes that although much of the land is rural, a substantial portion of the population is concentrated in urban centers like Indianapolis, Fort Wayne, Evansville, and South Bend.^4,5

Rural counties in Indiana are characterized by low population density, agricultural or manufacturing-based economies, and extensive land dedicated to farming, forestry, or natural landscapes. Demographically⁶, these areas are predominantly White, with significantly lower proportions of Black, Hispanic, and Asian residents compared to urban regions. Historically, rural economies in Indiana have relied on agriculture, small-scale manufacturing, and resource extraction; however, many have faced decline due to automation, globalization, and broader economic shifts.⁷ This has culminated in stagnant or declining population trends, higher unemployment or underemployment rates, and lower household incomes accompanied by elevated poverty rates. Furthermore, limited access to broadband internet in rural counties of Indiana presents a significant barrier to education, telehealth, and remote work opportunities.⁸

Rural Indiana faces significant barriers to both healthcare and education access that impact the well-being of its residents. In terms of healthcare, there are fewer hospitals and healthcare providers, particularly specialists, which forces individuals to travel longer distances to receive necessary care.⁹ This situation is exacerbated by higher rates of chronic illnesses, substance abuse¹⁰, and mental health needs among the rural population.⁹ Similarly, rural schools operate under constraints such as smaller budgets and staff shortages, making it challenging to attract and retain qualified teachers.⁹ Understanding the complexities of Indiana’s rural character goes beyond population statistics. It requires acknowledging the unique needs and realities of rural residents in statewide planning and infrastructure investments. This dual identity of Indiana, with its sprawling urban hubs alongside deeply rural regions, underscores the importance of equitable and effective policymaking that addresses the diverse challenges faced by all Hoosiers.

Race & Ethnicity in Rural Indiana

According to data from the U.S. Census Bureau, the Non-Hispanic White population constitutes the majority across the 92 counties in Indiana, comprising approximately 76.0% of the total population.¹¹ In rural Indiana, the demographic landscape has limited racial and ethnic diversity.

Age Distribution in Rural Indiana⁶

The age distribution across Indiana's rural counties reveals notable demographic patterns. This relatively balanced representation of younger and older age groups suggests a dual demand for services catering to both children and adolescents, as well as seniors over 65 years old. The remaining 58.3% of the rural population fall within the working-age population of 18 to 64 years. This distribution is illustrated in the adjacent pie chart, which highlights the balance between youth (under 18), working adults (18-64), and older residents (65 and older). Understanding this age spread is vital for strategic healthcare, education, and senior service planning in rural Indiana.

Gender Distribution in Rural Counties

According to the County Health Ranking & Roadmaps data for Indiana, the gender distribution in Indiana's rural counties is approximately 50.2% male and 49.8% female.⁶ This near parity reflects broader demographic trends in rural areas, where population dynamics are influenced by factors such as employment opportunities, migration patterns, and age distribution.

Educational Attainment

Educational attainment is closely linked to health outcomes, employment opportunities, and economic mobility. Individuals with higher levels of education tend to experience better health literacy, make healthier lifestyle choices, and utilize healthcare services more effectively. In Indiana, the statewide high school completion rate stands at 90%, aligning closely with the national average of 89%. However, disparities emerge when comparing rural and urban areas. Approximately 89% of rural residents in Indiana have completed high school or higher education, compared to 92% of urban residents—a modest 3% gap that reflects broader inequities in access to educational resources.¹³ This gap is more pronounced at the county level: in 32 of Indiana’s 64 rural counties, the percentage of residents with at least a high school diploma falls below the state average, while only one urban county falls below that threshold. Additionally, only 63% of Hoosiers have access to higher education, compared to 68% nationally.¹⁴ This limited access to postsecondary education and specialized vocational training in rural areas is often exacerbated by a lack of nearby institutions and reliable transportation. These barriers hinder opportunities for career advancement and economic growth, reinforcing a cycle of limited resources and lower health outcomes.

Family Structure

Understanding the dynamics of family structure can inform strategies to support vulnerable families and improve outcomes in education, health, and economic security. Single-parent households in rural Indiana face significant challenges that adversely affect both physical and emotional health outcomes for children. From 2018-2022, Indiana’s average percentage of family households with a single parent was 34.9%, with rural communities having a lower average percentage of 32.6%. While rural areas show a slightly lower prevalence of single-parent households, the issue in rural is influence by other layers of social determinants specifically impacting rural residents adversely. Research indicates that rural single-parent families particularly those headed by women experience higher poverty rates than married-couple families.

Income and Poverty

In Indiana, the economic landscape illustrates a clear contrast between rural and urban counties, particularly in terms of average household income and employment. Economic disparities between rural and urban Indiana are a significant factor in health outcomes, affecting everything from access to healthcare to quality of life.¹⁷ The average household income in rural areas stands at $63,469, which is significantly lower than $71,530 for those living in urban settings.¹⁸ This income gap can directly affect residents' ability to afford quality healthcare, nutritious food, and the resources essential for good health. The poverty rate for children under 18 years old in rural Indiana is 15%, which is the same as Indiana’s average, but higher than the urban counties (14%).¹⁹ These economic shifts contribute to the financial instability of rural communities.²⁰ Addressing these economic challenges is crucial for improving the overall prosperity and well-being of rural communities in Indiana.²¹    

Employment and Commuting

Several occupations dominate the employment landscape in rural Indiana, reflecting the region's agricultural strength and supporting industries. Agricultural workers are foundational, with Indiana ranking among the nation's leading producers of corn, soybeans, and hogs.²² This creates demand not only for farmers and farm laborers, but also for managerial roles within the sector. The state's agricultural success also fuels employment in food processing and manufacturing, particularly in areas where processing facilities are situated near raw material sources.²²

Rural Indiana is experiencing significant healthcare workforce shortages, exacerbated by an aging population and limited access to medical services.⁹ Additionally, the construction industry in Indiana is facing a workforce shortage, particularly in skilled trades such as carpentry, electrical-work, welding, and plumbing.²³ This shortage impacts the manufacturing and construction sectors that are essential for maintaining and developing rural infrastructure. Efforts are underway to address these gaps through vocational programs and apprenticeships aimed at  attracting new talent to these fields.²³ Finally, warehousing and logistics occupations are growing due to the increasing need to efficiently transport agricultural products and manufactured goods across the state and beyond.¹⁷

Manufacturing dominates the job landscape in rural Indiana, This reflects the presence of numerous production facilities in rural communities, where lower land costs and centralized transportation routes offer strategic advantages. The second- and third-largest sectors in rural areas are retail trade (13.0%)—which includes general merchandise stores and automotive dealerships—and accommodation and food services (7.7%), reflecting the importance of small-scale tourism and hospitality businesses.¹⁷

Unemployment Rate²⁴

Since 2002, Indiana’s unemployment rates have consistently remained below the national averageThe monthly unemployment rate in Indiana for May 2025 is 3.9%, compared to the national rate of 4.2%.²⁵ Overall, the Indiana unemployment rate is 3.0%, compared to 4% nationally. Many of the counties with an unemployment rate higher than the state's are rural counties.²⁶ It is important to note that certain employment opportunities provide not only salaried income but also health insurance coverage. Although rural Indiana’s unemployment rate—2.3% as of May 2022—is slightly below the statewide average, job quality and stability in rural areas may still be lacking. Many rural Hoosiers are employed in low-wage, part‑time, or precarious jobs, often with unreliable hours, limited benefits, and barriers such as inadequate childcare and transportation. These economic stresses can undermine access to care and raise the risk of stress-related health issues, including mental health challenges and chronic disease.

Commuting

On average, 32% of Indiana workers drive alone and have a commute longer than 30 minutes; however, in rural Indiana, this average percentage increases to 38%.²⁸ This trend may suggest a reliance on employment opportunities outside county borders, likely due to limited local job availability. The data reflects a significant transportation burden in rural Indiana, underscoring the importance of addressing infrastructure, economic development, and job accessibility in these regions.

Chronic Illness and Disability ^24,29

Chronic health issues like heart disease and diabetes are more common in rural settings. Exacerbating causes involve a combination of lifestyle, environmental exposure, and limited access to ongoing care and specialtyservices. Rural communities also tend to be home to aging populations with lower incomes, where 18% of rural residents are over the age of 65, compared to 15% in urban areas. Experiences with chronic illnesses and disabilities often intersect with aging populations, as a higher percentage of elderly residents utilize healthcare services for chronic disease management, mobility support, and long-term care.

In Indiana, the prevalence of disability reveals a slight contrast between rural and urban counties, impacting the overall health and well-being of residents. Approximately 85.8% of rural individuals report no disability, compared to 88% in urban areas.³¹ Conversely, 8.7% of rural individuals report having one disability, compared to 7.0% in urban counties.³¹ While this may seem like a modest difference, the impact on quality of life is substantial. Rural areas often face challenges such as fewer healthcare facilities, longer travel distances to receive care, and limited access to specialists, which can exacerbate health issues and hinder the effective management of disabilities.³²

Life Expectancy and Mortality

Residents in rural Indiana face shorter life expectancies and higher mortality rates across a range of categories. The average life expectancy in Indiana is 76.3, with the average life expectancy in rural counties being 76.0, compared to 76.9 in urban counties.³³ Rural counties have a higher premature age-adjusted mortality rate of 419.4 per 100,000 compared to urban counties, 398.1 per 100,000.¹⁷

Major factors contributing to mortality include drug overdoses, motor vehicle fatalities, and chronic disease burden.³⁴

Motor vehicle crash fatality rates are considerably higher in rural counties due to factors such as reduced access to trauma care, longer emergency response times, and less consistent seatbelt usage.³⁵ According to the Indiana University Public Policy Institute's Indiana Crash Facts 2021 report, 60% of motor vehicle crash fatalities occurred in rural areas, despite these areas having a smaller proportion of the state's population.³⁵

Chronic diseases such as heart disease, diabetes, and cancer are more prevalent in rural Indiana, where residents often face barriers to preventive care and limited healthcare provider availability.⁹

Behavioral Health Risks

Behavioral health risks, particularly smoking and obesity, remain significantly higher in rural counties, contributing to overall poorer health outcomes.³⁶

Smoking prevalence in Indiana is significantly higher in rural counties, where approximately 20% of residents are smokers, compared to 18% in urban counties.³⁷

Obesity rates in Indiana exhibit a notable rural-urban disparity. According to the Behavioral Risk Factor Surveillance System (BRFSS) data, 36.3% of adults in rural areas were classified as obese, compared to 33.3% in urban areas.³⁸ While this difference may appear modest, it underscores broader systemic challenges faced by rural communities. Obesity is also a major risk factor for chronic diseases such as diabetes, hypertension, and cardiovascular disease, further straining the healthcare system.³⁹

Housing⁴⁰

Access to safe, stable, and affordable housing is a fundamental determinant of health, yet it remains a persistent challenge in many rural areas including rural Indiana. In rural communities, limited housing supply, builders seeking more profitable builds, and high housing costs relative to income levels contribute to housing insecurity and instability. In rural Indiana, the issue is compounded by lower average incomes, fewer rental options, and limited development of new housing, particularly housing that is affordable for low-income families, seniors, or individuals with disabilities.

Housing availability in rural Indiana is influenced by a complex mix of economic, demographic, and structural factors. One of the most significant drivers is population growth, which Indiana has continued to experience steadily since 2017. This growth, when paired with consistently low unemployment rates and increasing earnings, has contributed to a competitive housing environment. As a result, residential inventory has declined, creating a seller’s market and driving up demand across much of the state.

Between 2014 and 2022, Indiana saw a significant 80% drop in active home listings, while home sales continued to rise since 2014. Despite this surge in demand, new home construction has not kept pace. Since the 2008 recession, the rate of new builds and construction bids has remained relatively stagnant. Although some counties have experienced modest development, most rural Indiana counties continue to face less dynamic and slower-moving real estate markets compared to their urban counterparts.

Importantly, housing affordability has also been strained. Even prior to the COVID-19 pandemic, Indiana was already grappling with inflated sale prices, largely due to early signs of housing shortages. One telling indicator is the 61% decline in home sales under the $150,000 threshold. What were once considered starter homes within this range are now often priced closer to $240,000, effectively pricing out many first-time buyers.

Several other factors continue to exacerbate the issue of affordability: 1) Builders are facing increased operational costs that go beyond general inflation; 2) there is a growing preference among developers to pursue more profitable, higher-margin projects, particularly in suburban or urban regions; and 3) the lack of available land plots, limited skilled labor, and lower potential returns further disincentivize new construction efforts. Altogether, this increases economic strain, reducing mobility and limiting access to services tied to housing location.

Impact of Rurality on Health Outcomes and Mortality^24,41,42

Limited healthcare access is exacerbated by transportation barriers that lead to missed rides, missed appointments, and increased ER usage. Outcomes include scheduling setbacks, delayed access to care, living with chronic pain, and the worsening of health conditions over time. Rural residents (87%) tend to live in primary care shortage areas, with the entirety of the state having only 230.8 physicians per 100,000. Rural residents are less likely to engage in preventive medicine, dental care, behavioral health (1 psychiatrist per 30,000 residents), and are susceptible to chronic disease.

Historically, rural Indiana’s causes of mortality have remained consistent over time excluding COVID-19. Heart disease, cancer, and accidents labeled as unintentional injuries have been the primary causes of death, which is reflected in the Nonmetro Leading Causes of Death table.

Data Limitations

Use of data from tools such as CDC WONDER presents a primary constraint, as it limits users’ ability to analyze multiple variables simultaneously despite the robust nature of the data. This restricts the ability to cross-reference key indicators like age-adjusted mortality rates with socioeconomic status or healthcare availability, thereby limiting deeper intersectional analyses.

Furthermore, many datasets were collected during or shortly after the COVID-19 pandemic, a period marked by widespread disruptions to healthcare access, shifts in health behaviors, and increased mortality risks. These conditions may skew indicators such as overdose rates, preventive care utilization, and mental health outcomes, making it difficult to determine whether observed patterns represent lasting trends or short-term anomalies.

The timeliness and granularity of available data also present challenges. While national sources like the U.S. Census Bureau offer broad demographic and economic indicators, they often fail to capture recent shifts or the distinct variability across rural counties. For example, life expectancy and educational attainment can differ significantly between counties, complicating efforts to generalize findings across rural Indiana. These limitations highlight the need for more localized, up-to-date, and multifaceted data collection to better inform rural health planning and interventions.

The Nonmetro Leading Causes of Death table was queried using the 2013 urbanization option via CDC WONDER to highlight Micropolitan (Nonmetro) and NonCore (Nonmetro) areas within the state of Indiana for the year 2022. All data was initially grouped by the 15 leading causes of death (see ICD-10 codes) in the rural sections of the state with the crude mortality rate being calculated per 100,000 individuals. Age-adjusted rates are for the entire state of Indiana regardless of rurality due to the inability of the CDC WONDER tool to granularly produce the data.

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Healthcare Workforce Shortages

 Key Data Highlights

• Severe provider shortages in rural Indiana affect both physical and mental health services, with projected shortfalls of up to 48,000 primary care physicians and a current 1:1200 mental health provider-to-patient ratio in some areas.
• Access to opioid treatment is limited, with 30% of rural counties lacking buprenorphine providers, compared to only 2.2% of urban counties, highlighting major treatment gaps for opioid use disorder.
• Healthcare deserts are widespread, with HPSA and MUA scores consistently indicating insufficient access to primary, mental, and dental care in rural counties.
• Emergency response capabilities are inadequate, as half of Indiana counties qualify as ambulance deserts, leaving over 100,000 residents at risk due to long EMS response times and limited availability.

Introduction

Rural areas face significant shortages in healthcare professionals and represent the majority of regions classified as health professional shortage areas as of early 2022. Compared to urban areas, rural communities have about half as many healthcare providers per capita: they average only 4 dentists per 10,000 people versus 7 in urban areas, 17 mental health providers versus 26, and 5 primary care doctors versus 8 per 10,000 people.^24,43,44

Counties within Health Professional Shortage Areas⁴⁵

Health Professional Shortage Areas (HPSAs) data helps identify rural counties experiencing health professional shortages by analyzing both the geographic distribution and the specific types of healthcare providers that may be lacking in those areas. These scores help identify regions with significant gaps in healthcare access, whether for primary care, dental, or mental health services. It highlights these areas by considering a combination of factors, including population size, geographic isolation, and the presence of medically underserved areas or populations.

A HPSA score is generated for each of Indiana's counties which represents the Health Professional Shortage Area (HPSA) score developed by the National Health Service Corps (NHSC) which designates need and priority attention by healthcare providers. The scores range from 0 to 26 where the higher the score, the greater the priority or need for more healthcare professionals. Rather than providing highly specific details, HPSA scores offer a somewhat of a general average of healthcare access across rural regions, painting a picture of where shortages are most prominent. These scores effectively pinpoint “desert” areas—regions with limited or no access to essential healthcare services—bringing attention to places where additional support and resources are critically needed. The scores range from 8.5 to 18.8 where lower scoring (less support needed) rural counties are depicted with light red shading, and higher scoring (more support needed) counties are depicted with darker shades of red.

A potential correlation can be inferred by showing that existing patient access to rural healthcare facilities can be attributed to a HPSA score.

Emergency Medical Services (EMS) play a critical role in protecting the health and safety of rural communities across Indiana. In regions where hospitals and specialized care facilities may be many miles apart, EMS professionals are often the first—and sometimes only—line of defense during medical emergencies. These frontline responders provide essential pre-hospital care, rapid transportation, and life-saving interventions that can mean the difference between life and death.

However, rural Indiana is experiencing significant healthcare workforce shortages that are severely impacting the effectiveness and sustainability of EMS systems. Limited staffing, aging personnel, long response times, and financial constraints are contributing to a crisis that threatens the accessibility and quality of emergency care. Small EMS agencies in rural counties often struggle to recruit and retain qualified paramedics and EMTs, leading to increased burnout among existing staff and reduced coverage for emergency calls.

As Indiana's rural populations continue to age and chronic conditions become more prevalent, the need for reliable EMS coverage is growing. Nearly 50% of Indiana’s counties represent an ambulance desert. Ambulance deserts are classified as regions that are more than 25 minutes away from an ambulance service station. Based on this criteria, 100,000 rural Indiana residents are left at risk. Due to lower population concentrations and limited availability of regional emergency medical services (EMS), emergency trauma transportation times in rural areas vary significantly from 17-30 minutes compared to urban/suburban communities’ average time of 3 minutes.

Healthcare Workforce Shortages and Residency Programs^46–48

Over the next decade, the United States is expected to face a physician shortage of between 37,800 and 124,000 providers. Specifically, by 2034, Indiana is expected to have a shortage of 17,800 to 48,000 primary care physicians, further exacerbating existing shortages, disparities, and associated comorbidities.

Residency programs serve as a crucial transition between completing medical school and becoming a board-certified, practicing physician. When including the initial years of medical school, this path typically requires about 7 to 10 years of rigorous education and training. As the U.S. population continues to grow steadily (8.4% growth by 2036), the demand for healthcare increases, which in turn raises the physician-to-patient ratio. The aging population of Indiana is compounding this issue, as these groups tend to utilize more services, increasing demand. In the next ten years hoosiers aged 65 or older will increase by 34.1% and individuals aged 75 or older will increase by 54.7%.

Not only are more patients requiring and receiving care, but a significant portion of the physician workforce is opting for retirement or shifting to roles outside of direct patient care. This shift places even greater strain on the already overextended healthcare system. The presenceor absenceof primary care physicians often serves as a strong indicator of a community’s overall health, as they represent the first point of access to qualified medical care for many individuals. With already low health provider shortage, these issues are magnified in rural areas. .

Rural residency programs are extremely important in addressing primary care shortages in rural areas, as research has found that residents who receive at least 50%+ of their training in rural areas are five times more likely to stay and practice in rural communities.⁴⁹ The Rural Residency map reflects Indiana’s residency programs with Federal Office of Rural Health Policy (FORHP) rural training sites, including programs that have 50% or greater training time in FORHP rural sites.⁵⁰      

Mental Health Providers⁵¹

The shortage of mental health providers has become a defining challenge in the broader healthcare workforce crisis nationwide, affecting rural areas most acutely. As demand for mental health services continues to rise—driven by factors such as increasing rates of anxiety, depression, substance use, and suicide—the supply of qualified professionals has not kept pace. This growing gap between need and availability poses significant risks to public health, particularly in underserved regions.

In many rural areas, including much of Indiana, access to licensed mental health professionals such as psychiatrists, psychologists, social workers, and counselors is extremely limited or nonexistent. Long wait times, provider burnout, and geographic isolation only exacerbate the problem. For residents in these areas, common barriers include distance, cost, and lack of providers accepting new patients.

The aging mental health workforce further intensifies this shortage throughuneven distribution of providers and a training pipeline that cannot meet the growing demand. The result is a strained system where too few professionals are left to serve too many, often leading to unmet needs, worsening symptoms, and higher rates of crisis-level interventions. Currently, over three-quarters of rural Indiana counties insist that mental healthcare is a key concern. At present, Indiana reports a concerning ratio of behavioral health providers to patients at 1:1200, and the ratio is even higher for rural Indiana.

Buprenorphine is a critical medication used to treat opioid use disorder (OUD), offering a safe, effective, and evidence-based pathway toward recovery. As a part of medication-assisted treatment (MAT), buprenorphine helps reduce cravings, prevent withdrawal symptoms, and lower the risk of fatal overdose. Despite its proven effectiveness, access to buprenorphine remains uneven, especially in rural and underserved communities due to the lengthy, mandated “X-waiver” process implemented by the DEA. The process could potentially delay treatment up to forty-five days, which is could be fatal when dealing with at-risk populations who require treatment.⁵²

Rural areas like those in Indiana struggle to address numerous barriers to buprenorphine access. These include a shortage of licensed prescribers, stigma surrounding treatment, restrictive policies, and geographic isolation that make it difficult for patients to reach clinics or pharmacies that dispense the medication. While recent federal changes have reduced some of the regulatory burdens around prescribing buprenorphine, significant disparities in access and availability persist. Currently, about 30% of rural U.S. residents live in counties with no buprenorphine provider compared to only 2.2% of urban residents. 

Data Limitations

Several limitations must be considered when interpreting healthcare access and workforce data in Indiana, particularly regarding the use of HPSA and Index of Medical Service (IMU) . A primary challenge lies in the fact that these two metrics use inverted value systems—higher HPSA scores denote greater need, whereas lower IMU scores indicate higher levels of medical underservice. Without clear contextualization, this inversion can lead to misinterpretation during comparative analysis. Additionally, the tool used to display residency program availability introduces their own limitations. Specifically, the platform allows only three specialties to be displayed simultaneously, with the option to mix and match between disciplines such as internal medicine, family medicine, and obstetrics. This constraint may obscure the broader distribution of programs and limit comprehensive understanding of statewide training opportunities. Furthermore, essential specialties such as addiction medicine, geriatrics, and psychiatry may be underrepresented or entirely absent in these tools due to their relative scarcity, despite being critical to rural and underserved populations.

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Health Insurance

 Key Data Highlights

• The rate of uninsured in rural areas is 9%, which is higher than the state average.
• In Indiana, for rural counties, 86% of Medicaid recipients are enrolled in Medicaid only, while 14% are dually eligible for both Medicaid and Medicare.

Introduction In Indiana, .⁵⁴ An article from the Indianapolis Business Journal highlights the rural areas in Indiana that face significant healthcare gaps, which complicate patient outcomes.⁵⁵ These gaps are attributed to a shortage of healthcare providers, longer travel distances to medical facilities, and reduced availability of specialized services.⁵⁵ Consequently, rural residents are less likely to receive preventive care and timely treatments, contributing to higher rates of chronic diseases and mortality compared to their urban counterparts.⁵⁵ The combination of lower income levels and higher healthcare costs in these regions exacerbates the issue, leading to a higher uninsured rate among rural populations.⁵⁶

Medicaid and Vulnerable Rural Populations in Indiana

In Indiana, Medicaid is a vital lifeline for nearly two million residents, with approximately a quarter of all enrollees residing in rural areas.⁵⁷ Thus, a considerable number of these extremely vulnerable populations reside in rural areas where access to care is already compromised. These individuals often face compounded barriers due to poverty, limited healthcare infrastructure, and workforce shortages. Counties designated as rural by HRSA show that 86% of Medicaid recipients are enrolled in Medicaid only, while 14% are dually eligible for both Medicaid and Medicare.⁵⁷ The demographic profile reveals a population primarily composed of working-age adults (49%) and children (42%), with seniors comprising just 9%. This distribution  emphasizes the program’s role in supporting low-income families and younger individuals.⁵⁷

Eligibility for Medicaid in Indiana varies by age and life circumstances. Adults aged 19 to 64 qualify for coverage with incomes up to 138% of the Federal Poverty Level (FPL), while children and pregnant women qualify at higher income thresholds. Programs like the Healthy Indiana Plan (HIP) offer coverage for qualified adults, incorporating a consumer-driven model that incentivizes preventive care.⁵⁸ However, the requirement for monthly contributions of 2% ⁵⁹of family income can be a financial barrier for households already struggling to meet basic needs.

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Healthcare Facility Availability

Key Data Highlights

• Rural Indiana faces major healthcare access disparities, with far fewer providers per capita than urban areas. such as 5 .versus 8 primary care doctors and 4 versus 7 dentists per 10,000 people. Shortages in mental health and obstetric care–27 counties lack labor and delivery services—further impede healthcare access for rural residents.
• Healthcare access points go beyond hospitals to include services like addiction treatment centers, urgent care, and long-term care facilities, all of which are limited in rural areas, further strained by transportation barriers and public transit shortages.
• Trauma and emergency care are critically under-resourced, with many residents living far from trauma centers; although statewide 92% of Hoosiers are within 45 minutes of trauma care via highway, geographic and transport gaps still endanger timely access to life-saving treatment.
• Mental health professional shortages are severe, with some rural counties having up to 59,000 residents for every one mental health counselor, and data reliability may be limited due to small rural populations.

Introduction

In Indiana, the rural healthcare landscape is anchored by a network of essential facilities that provide critical services to communities across the state. As of May 2025, Indiana is home to 33 Critical Access Hospitals (CAHs), strategically distributed to serve rural populations.⁶⁰ These hospitals are designed to enhance healthcare delivery in underserved areas by offering 24/7 emergency care and maintaining no more than 25 inpatient beds, thereby ensuring that residents have access to necessary medical services without the need to travel long distances.⁶¹

CAHs play a pivotal role in the state's healthcare system, often serving as the sole hospital within a considerable radius. They are complemented by other vital facilities, including Federally Qualified Health Centers (FQHCs), community health centers, and rural health clinics, which collectively contribute to a comprehensive care network. This network extends beyond primary care to encompass specialized services such as urgent care clinics, addiction treatment centers, private physician practices, and specialty clinics, which address a wide spectrum of health needs within rural communities.

Despite the presence of these facilities, rural residents in Indiana face significant challenges in accessing healthcare services, with transportation being a primary barrier. Nationally, only 33% of rural residents have access to public transportation, compared to approximately 75% of urban residents. In Indiana, this issue is particularly acute for the nearly 20% of older adults residing in rural areas, where limited mobility can exacerbate health disparities.⁶² Limited infrastructure, declining tax bases due to youth outmigration, and inadequate reimbursement structures that discourage providers from offering long-distance services are factors contributing to transportation challenges. These systemic issues underscore the need for targeted interventions to improve healthcare accessibility and equity across rural Indiana.

Obstetric Services^63,64

In addition to the limited supply of current healthcare facilities, many of the access points are being closed through hospital closures, mergers, and acquisitions. As of 2024, 52 rural hospitals in Indiana are in operation, and 25% have removed some services due to expensive fixed costs. One such service that is experiencing significant decline in rural areas is obstetrics (OB). In Indiana, maternity care services are concentrated in metropolitan areas, primarily around Indianapolis, Fort Wayne, and near Chicagoland. Currently,  35 counties lack a hospital with birthing facilities, including 24 counties outside metro areas. With a total of  255,117 women of childbearing age residing in non-metro counties, 93,234 women of childbearing age live in counties without a birthing hospital. Additionally, 27 of Indiana's 92 counties have no labor and delivery provider at all.  

For more details, refer to the Maternal and Infant Health Section.

Access to trauma centers in rural Indiana mirrors the challenges faced across a wide spectrum of specialized and supportive healthcare services. Like dialysis centers, mental health clinics, and addiction treatment facilities, trauma care is a vital access point, but it carries a unique level of urgency. For many rural residents, the nearest trauma center may be an hour or more away, creating a dangerous gap in care when minutes can mean the difference between recovery and tragedy.

While all healthcare services play an essential role in maintaining community health, trauma centers stand apart due to the time-sensitive nature of the care they provide. Whether it is a serious car accident, a stroke, or a severe injury from farming equipment, the type of trauma and the speed at which care is delivered are critical factors in survival and long-term outcomes. In these moments, geographic distance and limited transportation options become life-threatening barriers

 Most rural counties in Indiana represent a ratio residents per behavioral health and human services (BHHS) professional, while others represent  ratios ranging from 2,377 and 4,26

residents per BHHS professional. Additionally, the geographic distribution of mental health counselors for rural Indiana displays resident to counselor ratios residents per one mental health counselor FTE and a wider range of ratios spanning between 17,837 and 59,183 residents per mental health counselor FTE. The visual regarding the geographic distribution displays lighter shading for predominantly rural areas indicated by low FTE for behavioral health and human services professionals.

Data Limitations

While the data presented provides valuable insights into rural healthcare access and disparities in Indiana, there are several important limitations to consider when interpreting the findings.

First, lower population sample sizes in many rural counties can lead to statistical variability that may slightly skew results. Additionally, some rural areas in Indiana that are classified as non-metro may still have proximity or economic ties to nearby urban or suburban communities, which could influence access to healthcare services and inflate metrics that do not accurately the impact experienced by rural populations in other places.

Second, it is important to note that some of the data may not accurately capture the current post-pandemic healthcare landscape. Due to the disruptions caused by COVID-19, including restricted access to in-person care, delayed procedures, staffing shortages, and altered healthcare-seeking behavior, data collected during or prior to the pandemic may not be fully representative of present-day trends. The pandemic’s long-term impact on both patient outcomes and provider availability is still unfolding, and any comparative analysis between pre- and post-pandemic periods should be interpreted with caution.

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Mobile Integrated Health Programs in Rural Counties of Indiana

Key Data Highlights

• MIH initiatives have shown measurable benefits, including reduced 911 calls, lower readmission rates (up to 83% in some pilots), and improved patient outcomes through proactive, community-based interventions.

Introduction

Mobile Integrated Health (MIH) programs are revolutionizing healthcare delivery by extending services beyond traditional clinical settings. In rural Indiana, where healthcare access is often hindered by distance, provider shortages, and socioeconomic challenges, MIH programs are emerging as a lifeline. These programs empower emergency medical services (EMS) and community paramedics to provide in-home care, chronic disease management, and follow-up services. This section explores the current landscape, successes, and challenges of MIH programs in rural Indiana, offering policy recommendations to support their sustainability and expansion. As rural hospitals continue to close or downsize, MIH represents a critical innovation in rural healthcare delivery.

Current State of MIH in Rural Counties of Indiana

Indiana has seen a steady rise in MIH programs, particularly in rural counties lacking more robust healthcare infrastructure. At least two rural counties, Adams and Daviess, have already implemented MIH programs to reach patients in remote areas.⁶⁸ These programs typically involve trained community paramedics who conduct wellness checks, assist with medication management, and provide education on chronic disease care. Many MIH programs collaborate with local hospitals, public health departments, and behavioral health organizations to ensure a holistic approach to care. According to the Indiana Department of Health, MIH initiatives have contributed to reduced non-emergency 911 calls and hospital readmissions in participating counties.⁶⁹

Impact & Outcomes

A study published in Population Health Management found that patients who initially presented at rural hospitals had a 30-day readmission rate of 12.1%, compared to 19.2% for those at urban hospitals. Similarly, research focusing on Medicare beneficiaries with diabetes indicated a 12.9% readmission rate for rural residents, versus 14.9% for urban counterparts.⁷⁰ MIH programs aim to reduce hospital readmissions through proactive measures such as home visits, medication reconciliation, chronic disease monitoring, and patient education. For instance, Citizens Memorial Hospital's Missouri, MIH initiative led to a 2.5% reduction in Medicare readmission rates within 10 months of operation.⁷¹ Another pilot study demonstrated an 83% reduction in hospitalizations post-MIH intervention, highlighting the effectiveness of such programs in decreasing acute care utilization.^71,72  Overall, the evidence shows MIH/community paramedicine can significantly reduce ED visits and hospitalizations, especially when social determinants (transportation, medication, housing, etc.) are addressed alongside clinical care.⁷³ These findings underscore the role of MIH programs in aligning rural hospital readmission rates with national averages, primarily through enhanced post-discharge care and addressing social determinants of health.

Challenges & Barriers

Mobile Integrated Health (MIH) programs in rural Indiana offer promising solutions to healthcare access challenges, yet they face several significant hurdles, such as funding and reimbursement. Many MIH programs in Indiana are initially funded through short-term grants, such as the Health Issues and Challenges Grant administered by the Indiana Department of Health. For instance, Clark County's MIH initiatives received approximately $715,000 combined state and local funding to support program development.⁷⁴ However, sustainable reimbursement models remain a challenge. Traditionally, Medicaid and Medicare reimbursements for EMS services are tied to patient transport, limiting compensation for community paramedicine services that focus on in-home care.⁷⁵

To bolster the growth and sustainability of Mobile Integrated Health (MIH) programs in Indiana, several strategic policy interventions are recommended: ​

1. Expand Medicaid Reimbursement for Community Paramedicine Services: Historically, Indiana's Medicaid reimbursement for Emergency Medical Services (EMS) was limited to transportation services. However, a 2020 law initiated the decoupling of reimbursement from transportation, allowing for Medicaid reimbursement of in-home EMS services without transport, provided they respond to a 911 call. This change marks a significant step toward broader Medicaid coverage for MIH services. Further expansion of Medicaid reimbursement to encompass a wider range of MIH services would enhance program sustainability⁷⁵. ​

2. Invest in Rural Broadband Infrastructure to Support Telehealth: Effective MIH programs often rely on telehealth platforms to deliver care in patients' homes or mobile environments. Investing in rural broadband infrastructure is crucial to support these telehealth services, ensuring that patients in underserved areas have access to necessary healthcare resources⁷⁶

Data Limitations⁷⁷

Despite the growing presence and reported successes of Mobile Integrated Health (MIH) programs in rural Indiana, several significant data limitations hinder comprehensive evaluation and long-term planning. There is not a statewide requirement or standardized framework for collecting and reporting MIH program outcomes across Indiana. As a result, available data is often fragmented or inconsistent, limiting comparisons across counties or programs. Many MIH programs, especially those operating under pilot or grant-funded phases, may not have the infrastructure to collect long-term or detailed outcome data. This impedes efforts to track metrics such as patient satisfaction, cost savings, long-term readmission rates, or reductions in emergency department visits over time to make a strong economic case to policymakers or insurers for sustained investment.

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Telehealth Services

Key Data Highlights

• Telehealth usage has increased overall since before the COVID-19 pandemic but has fallen since pandemic-era highs.

• Both rural patients and providers have high rates of satisfaction with telehealth services.

• The future of telehealth in the state and nationally is dependent on regulations that have yet to be settled.

Introduction

Telehealth refers to the use of digital technologies, such as video conferencing, mobile apps, and remote monitoring tools to deliver healthcare services and information from a distance. It allows patients to consult with healthcare providers, receive diagnoses, manage chronic conditions, and access mental health support without traveling to a medical facility.This is especially important in rural areas, where residents often face barriers to care such as long travel distances to clinics, limited access to specialists, and shortages of healthcare professionals. Telehealth is one tool that can improve access to timely care, reduce costs, and support better health outcomes within rural communities.

Broadband as a Super-Determinate of Health

According to the Substance Use and Mental Services Administration, broadband is increasingly being considered a "super determinant" of health because it enables access to many other key health-related resources, such as telehealth, online education, job opportunities, and social services.⁷⁸ Without reliable Internet, individuals—especially in rural or underserved areas—face greater barriers to healthcare, health information, and the ability to manage chronic conditions, which can lead to poorer health outcomes and increased health disparities.

Indiana Broadband Access

Broadband is high-speed internet access that allows for fast and reliable data transmission. It is essential for telehealth because services like video appointments, remote patient monitoring, and accessing electronic health records all require a fast, stable internet connection. In areas without adequate broadband, especially rural communities, limited connectivity can prevent patients from using telehealth effectively, creating barriers to timely, quality healthcare.

According to BroadbandNow, Indiana ranks 27^th overall among all 50 states for combined speed and availability of internet.⁷⁹ However, that availability is not evenly distributed as reliability in rural areas is much lower in rural areas compared to urban areas, especially for lower-cost broadband.

2025 Broadband Coverage and Availability in Indiana⁷⁹

• Internet Ranking Among all 50 States for Speed and Availability: 27^th

• Statewide Access to Fixed or Wireless Broadband: 91.2%

• Access to Wired Low-Priced Broadband Plan ($60/month or less,excluding promotions and government programs): 81.2%

• Access to Fiber Optic Service: 51.7%

• Indiana Internet Providers: 260

 Characteristics of Individuals or Households with No Internet Access⁷⁹

 Indiana Broadband Speeds

According to Rural Indiana Stats, a collaboration between the Purdue Center for Regional Development and Indiana Office of Community and Rural Affairs, both broadband upload and download speeds are significantly lower in rural counties than they are in non-rural counties.⁸⁰ This has a significant impact on the ability of communities to connect with telehealth providers, as well as other online resources.

Required Speeds for Telehealth

For telehealth to work smoothly, especially video visits, a broadband connection with download speeds of at least 25 megabits per second (Mbps) and upload speeds of at least 3 Mbps is generally recommended. These speeds help ensure clear video and audio, quick data sharing, and a stable connection between patients and healthcare providers. Slower speeds can lead to poor video quality, dropped calls, or delays in communication. One recent study positively correlated telehealth usage with high-speed, reliable broadband access.⁸¹

Additionally, speed needs to increase as the number of providers using that connection increases. While most counties have average speeds that can support a patient receiving telehealth, many rural counties in Indiana do not have speeds that are recommended for the lower threshold for a healthcare practice operating telehealth. According to the Office for the National Coordinator of Health IT⁸² minimum broadband needs are as follows:

• A single provider – 4 Mbps

• A small practice or rural clinic – 10 Mbps

• A large practice – 25 Mbps

• A hospital 100 Mbps

According to Rural Indiana Stats (RIS), there are four different rural counties that would be unable to support the telehealth needs of a hospital.⁸² Additionally, it is important to note that minimum speeds are not the same as the ideal speeds for a platform to operate effectively. 

Federal Initiatives

It has become increasingly apparent that broadband is a vital accessibility tool in Indiana and nationwide. Steps are being taken on the national level to ensure that communities without access to broadband are not being left behind.

The BEAD Program

The BEAD (Broadband Equity, Access, and Deployment) program is a federal initiative that provides funding ($42 billion nationwide) to expand high-speed internet access across the United States, especially in unserved and underserved areas. Its goal is to close the digital divide by helping states build broadband infrastructure so that more people, particularly in rural and low-income communities, can access reliable internet for things like healthcare, education, and work.

BEAD by the Infrastructure Investment and Jobs Act and is overseen by the National Telecommunications Information Administration (NTIA). BEAD prioritizes unserved locations that have no internet access or limited access under 25/3 Mbps and underserved locations that only have access under 100/20 Mbps.⁸³

Indiana has been awarded $868 million in BEAD funds to ensure that every Indiana resident has access to high-speed, reliable, affordable broadband access. As of April 2025, the Indiana Broadband Office (IBO) has made preliminary awards in Round 1 of the BEAD Program. The awards will provide broadband access to more than 90,000 locations, which the office says is about 70% of the eligible locations. Round 2 of funding closed taking application in June 2025.⁸⁴

Indiana and the Digital Divide

The digital divide refers to the gap between people who have access to reliable internet and digital technology and those who do not. In rural communities, this divide is often more severe due to limited broadband infrastructure and affordability issues. As a result, residents may struggle to access online services like telehealth, education, and job opportunities, which can widen existing disparities in healthcare, economic development, and overall quality of life.

There are multiple ways to measure the impact and presence of the digital divide. One such  method is the Digital Divide Index (DDI) which is calculated by the team at Rural Indiana Stats (RIS). The DDI is composed of two scores: the infrastructure/adoption (INFA) score and the socioeconomic (SE) score. These two scores measure variables related to broadband infrastructure and adoption and variables related to technology adoption. ⁸⁰

According to the average DDI across the state, rural counties have a higher average digital divide index, indicating higher levels of digital inequity. This difference indicates that rural and partially rural counties have more marked digital divides on average.

Telehealth and other digital health advances are promising ways to connect rural Hoosiers with more accessible care. However, these advances are often limited by availability of high-speed, reliable broadband. While broadband has become increasingly accessible thanks to initiatives such as the BEAD program, there are still gaps present in rural communities. Without deliberate attention, the existing digital divide that exists in rural communities will continue to widen.

Telehealth Services⁸⁵

Services allowed in Indiana that are included as “telehealth” under Indiana Administrative Codes (with some restrictions):

• Live Video

• Remote Patient Monitoring

• Audio Only

Telehealth Parity

Indiana does have coverage parity, but does not have payment parity.⁸⁵ Coverage parity for telehealth services means that health insurance plans are required to cover telehealth visits in the same way they cover in-person visits. This ensures that patients can access care remotely without facing higher costs or limited coverage compared to traditional appointments. Payment parity ensures that payment for telehealth and in-person services is equal.Indiana has not made any moves towards enacting payment parity yet.  

Telehealth Utilization

Before the COVID-19 pandemic, telehealth use was relatively low nationally, with limited adoption due to regulatory restrictions, low reimbursement rates, and a preference for in-person visits.⁸⁶ During the pandemic, however, telehealth use surged dramatically as emergency policies expanded access and patients and providers turned to virtual care to reduce the risk of virus exposure. After the peak of the pandemic, telehealth use has declined from its highest levels but remains significantly higher than pre-pandemic rates, as many patients and providers continue to value its convenience and flexibility. Services that have been sustained at the highest levels are related to behavioral health.⁸⁷

Utilization Rates – 2021⁸⁷

Nationwide, an estimated 37% of adults in the U.S. used telehealth during the year. Midwest rates are the lowest overall compared to other regions (South, West, Northeast) with just 33.3% of adults using telehealth during the year. National rates showed that telehealth use dropped the further populations were from metropolitan areas and areas only saw 27.5% telehealth utilization during the year.

Rural Provider and Patient Satisfaction

Nationally, telehealth utilization rates have been lower in rural communities compared to urban areas, due in part to challenges such as However, despite these barriers, patient and provider satisfaction with telehealth services in rural settings has remained high, aligning with national satisfaction trends. Indiana-specific telehealth satisfaction data is currently unavailable, limiting the ability to assess how these trends apply within the state.

The information available focuses on rural providers and patients nationwide.⁸⁸ 

Satisfaction Rates -2021⁸⁸

• One study reported 73% of rural patients were satisfied with telehealth.

  • Rates of satisfaction were generally higher among younger patients.

• 80% of rural providers agreed that telehealth “added value” to their practice.

  • Provider age or time in practice did not have a significant impact on attitude towards telehealth.

  • 6% of providers found telehealth appointments “more efficient” than in-person appointment.

Telehealth Rules and Regulations

Telehealth practice is very dependent on what is both legal and reimbursable. The information in this section is current as of April 2025, but may change based on state or federal legislation. Changes to telehealth utilization in CMS codes happened rapidly at the beginning of the COVID-19 Pandemic. What the future of telehealth looks like nationwide and regionally is still being decided,with some services are allowed temporarily.. As of April 2025, of many of the Medicare telehealth flexibilities that were in place during the COVID-19 public health emergency have been extended through September 30, 2025.⁸⁶

Telehealth Service Reimbursement

This breakdown from the Upper Midwest Telehealth Resource Center provides an overview of which services are reimbursable by insurers within Indiana as of 2025.⁸⁹ 

Telehealth can potentially increase access to those within rural or isolated communities. While there is still data to be collected on the subject, it can tentatively be assumed that telehealth's improvements to care satisfaction and care access will continue to positively impact rural Hoosiers. However, these gains are very dependent on temporary allowances made for telehealth at a federal level.  Until permanent rules can be established, the long-term use of telehealth will remain limited in rural communities.

Data Limitations

Accurate and current data on telehealth usage specific to Indiana remains limited. While data collection has increased nationally since the COVID-19 pandemic, much of it remains unavailable at the state or regional level. The Digital Divide Index (DDI) used in this report primarily captures physical access and socioeconomic barriers to telehealth adoption but does not reflect comprehensive usage metrics. Therefore, the findings in this section are based on the best available data and should be interpreted as descriptive, serving as a foundation for further discussion rather than a complete picture of telehealth access in Indiana.

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Report Information

Disclaimer: 

The data presented in this report reflect the most current information available at the time of publication. However, due to the evolving nature of healthcare systems and ongoing data updates, some figures or details may have changed since the report was finalized. Readers are encouraged to consult the original data sources or relevant agencies for the most up-to-date information.

Questions or Media Inquiries

 For questions or media inquiries based on the contents of this report, please contact:

PH: 812-605-2639, Email: [email protected]