Our nation's health care crisis affects all Americans in different ways. A new report from the Department of Health and Human Services details the health care challenges faced by the some 50 million people living in rural America.

Hard Times in the Heartlands is an excellent collection of resources for understanding what hits home for rural Americans. The report makes several key points.

First, the report notes that the economic downturn has struck rural America especially hard. Rural areas are losing jobs at faster rates than the rest of the economy. Now, nearly one in five (8.5 million) of our nation's uninsured live in rural areas.

Farming plays a central role in the rural economy and more than 80 percent of the farms in the U.S. are run by a sole proprietor. This creates a unique situation in which nearly a third of all farmers purchase health insurance on the individual market–compared to just 8 percent nationally. Without the benefits of the large group market, these individuals face higher premiums, increased cost-sharing, and a greater likelihood of being denied coverage because of their health status or a pre-existing condition. On average, rural residents pay 40 percent of their health costs out-of-pocket with one in five spending more than $1,000 out-of-pocket.

Access to care is also an issue. Shortages of both primary care and specialists are particularly acute in rural America. There are half as many specialists per 100,000 residents in rural areas compared with urban areas, and a third as many psychiatrists.

The issues of access, coverage, and affordability conspire to accentuate disparities between rural and urban populations. Rural Americans are more likely to have chronic conditions like obesity and hypertension, but less likely to receive the recommended care and preventive screenings for conditions like diabetes and breast cancer.

The heartland may be hurting, but their cries have not gone unheard. Already the stimulus funding for health IT and broadband connectivity should help ease some of the access problems in rural America. Proposals to create a new health insurance marketplace can help provide Americans, such as rural farmers, who purchase insurance on the individual market with more choices at lower costs.

Health reform must address the challenges of cost, coverage and quality shared by all Americans, but in a manner that reflects the diversity of America and adapts to needs of different populations.