Rural transportation services

Evidence Rating  
Expert Opinion
Evidence rating: Expert Opinion

Strategies with this rating are recommended by credible, impartial experts but have limited research documenting effects; further research, often with stronger designs, is needed to confirm effects.

Health Factors  

Rural transportation services provide transportation across large areas that have low population densities and lack public transportation systems. Services may include shared transportation options such as publicly funded buses and vans running on fixed routes and schedules, smaller vehicles with more flexible pick-ups and drop-offs (e.g., dial-a-ride and other demand-response programs), or volunteer ridesharing programs1, 2.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased mobility

  • Increased access to health care

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Increased access to employment

What does the research say about effectiveness? This strategy is rated expert opinion.

Rural transportation services are a suggested strategy to increase mobility and access to health care for rural populations3, 4. Available evidence suggests that such services can increase mobility among vulnerable populations such as older adults, people with disabilities, and individuals with low incomes5, 6, and increase access to medical services5, 7, grocery stores, other retailers, and community activities8. However, additional evidence is needed to confirm effects.

Rural areas with limited or minimal transportation services are especially challenging for residents with health conditions that make driving difficult and make them reliant upon others to access health care services, grocery stores, and other resources9. A Canada-based study suggests that older adults living in rural areas are less likely to undertake a trip when they lack access to a ride than older adults residing in cities; experts recommend that travel for these residents be supported through community-based low cost transit options, such as carpools or vanpools arranged by non-profit or faith-based groups10. A California-based survey of residents of rural, affordable housing complexes reported that residents are willing to use ride sourcing and car sharing services located at their complex; however, these services generally require payment from a credit card or bank account, which not all residents have11. Transit by rural ride sourcing services is often arranged through websites or apps, which older adults may find challenging to use, especially if they have minimal previous internet experience, do not have a smart phone, or have limited broadband services12. A study based on national survey data suggests that growing rural communities are associated with increased commuting by public transportation, regardless of the timing of the commute13. A Texas-based study indicates that taxpayers value rural transportation services for older adults and are willing to financially support such services14. Efforts to improve rural transportation services should include increased funding and infrastructure assessments that consider accessibility, as rural areas continue to age at a higher rate than the rest of the country9, 15.

Rural transportation services may increase access to employment5, 16 and provide opportunities for higher wages for individuals who live in rural areas17. Rural transportation may benefit local economies18 by supporting the productivity and viability of local businesses through increased access for those who do not or cannot drive5. Furthermore, by supporting access to employment, transit may reduce government spending on public assistance programs such as the Supplemental Nutritional Assistance Program (SNAP)5 and allow people to reside in the community of their choice5.

Rural transportation networks often have high per capita costs and are frequently personalized based on the needs of users19. Efforts to track and evaluate the operating costs of rural demand-response programs can help improve performance and reduce program costs20. Experts suggest that modeling demand-response transit services in rural areas can be used by transit agencies to predict the ideal frequency of trips to meet the community’s transit needs, based on population density, number of older adult residents, and average income21. Transit agencies should engage rural residents and existing local programs with transportation components that serve rural residents who cannot easily travel, such as meal delivery services, medical transports, and senior centers, in the planning process15. To meet the transportation needs of rural populations, especially aging residents, partnerships between non-profits, governments, and the private sector, along with health care systems and disability service providers, are needed to coordinate and expand existing services; create additional transportation options; and remove barriers to transportation, such as advance scheduling requirements and limited run times for transit services12, 15. Organizations that serve rural residents can also partner to coordinate existing efforts to transport clients with similar routes or destinations6, 8.

Cost benefit analysis finds positive net benefits for rural transportation services overall22. Based on data from 2017, there were $2.20 in benefits for every dollar invested in Greater Minnesota rural transit services5.

How could this strategy advance health equity? This strategy is rated potential to decrease disparities: suggested by expert opinion.

Rural transportation systems have the potential to decrease disparities in mobility and access to health care for residents of rural areas, particularly older adults, individuals with disabilities, and individuals with low incomes, as they are less likely to be able to drive or afford private vehicles1, 3, 4, 5, 6. Available evidence suggests that establishing or expanding transportation services in rural areas can support transit equity for vulnerable residents who lack alternative travel options, which may also include immigrants and ethnic minorities13. Among these residents, improved rural transportation services may improve quality of life through access to care, employment, and opportunities for social connection and recreation1, 5. Lack of transportation services in rural areas can restrict access to health care and delay treatment for both acute and chronic health conditions, as well as limiting access to education, employment opportunities, and sources of fresh, healthy food29. Rural residents may become dependent upon family or friends when reliable transit services are unavailable in their community9. Rural residents who cannot afford or access transit services may experience increased social isolation9.

Rural populations are aging at a faster rate than those in urban or suburban areas and have higher rates of disability among residents; therefore, rural residents are more likely to have a condition which makes it difficult to drive, regardless of their ability to afford a private vehicle9. For older adults and individuals with disabilities living in rural areas without transportation services, losing the ability to drive and travel with ease may diminish their sense of control over their life, independence, and self-respect12. Older adults living in rural areas may continue to drive until forced to stop, as there are no alternative transportation services available12.

Even when transportation services are available in rural areas, the price of travel may still be unaffordable for those with the greatest need for services9.

What is the relevant historical background?

Public transportation systems, including rural transportation services, in the U.S. have been shaped by many factors, including car ownership, residential living patterns, federal funding, and the mass construction of interstate highways30. In the 19th century and early 20th century, streetcars helped define residential and commercial areas in cities31, while roads extended from railroad stops to connect rural areas to rail lines, bringing produce to urban areas and manufactured goods back to farming communities32.

In the 1950s, the creation of the modern interstate highway system alongside the growing popularity of suburban neighborhoods among white families fed into a dependence on private automobiles, leading to low density suburban development, urban sprawl, and declining investments in and services provided by public transit systems30. Highways generally followed existing railroad routes, which bypassed rural towns, cutting them off from the fledgling national transportation network, as well as dividing and destroying low income and Black neighborhoods in cities31, 33.

Rural transportation services can be more expensive to implement and maintain with the often substantial distances to cover between residential areas, schools, employment opportunities, and services such as health care, which can be compounded by current roads and bridges in disrepair, mountain passes, steep grades, and severe weather34. As rural health care facilities and employers consolidate, relocate, or close, the distances can become even greater, increasing cost of transit and further reducing access35. Federal funding for rural transportation is generally allocated to state departments of transportation that may not consult small, rural agencies when deciding how to spend the funds, leaving the transit needs of rural communities unmet34.

At the federal level, the Rehabilitation Act of 1973 was first passed to improve transportation access for individuals with disabilities and older adults. In 1990, the Americans with Disabilities Act (ADA) made additional attempts to improve transportation access and prohibited discrimination against people with disabilities, which included transportation accommodations36. Yet even with these laws, it is still difficult to access transit in rural areas.

As of 2022, 19% of Americans live in rural areas and 68% of all roads (9,494 lane-miles per 100,000 residents) in the U.S. are in rural areas. Rural communities are aging rapidly: models indicate that by 2040, rural communities will be made up of 25% of households that are 65 years old or older, compared to only 20% in urban communities. As of 2023, approximately one-third of adult residents of rural communities have a disability compared to the U.S. average of one-quarter35. Older adults, individuals with disabilities, and other rural non-drivers require mobility options to protect their health as well as their social and civic engagement35.

Equity Considerations
  • How are rural transit agencies connecting with local residents to learn where transit stations or stops are most needed and what frequency of service would be most helpful? Are these locations walkable, safe, and do they include shelter with accessible seating?
  • How can ridesharing and car sharing programs be equipped to accept alternative forms of payment (i.e., cash, vouchers, or membership passes) rather than only credit cards or bank accounts to increase access for rural residents with limited resources?
  • Do the staff members of public transportation, ridesharing, and car sharing programs speak the same languages as participants? Are program materials readily available in multiple languages and large print?
  • Which organizations in your community are already offering transportation services to particularly vulnerable residents such as older adults or individuals with disabilities? Who can coordinate partnerships between these organizations and rural transit agencies to learn more about community needs, create plans to fill transit gaps, and coordinate services?
Implementation Examples

The U.S. Department of Transportation, Federal Transit Administration provides Rural Area Formula Program Grants (Section 5311 grants) to states and federally recognized Indian tribes to be used for capital, planning, and operating assistance for transportation services in rural areas with populations of less than 50,00023. As of 2020, 83% of U.S. counties have some form of rural transit service; 464 rural transit agencies provide fixed-route service and 1,136 rural transit agencies offer demand-response services (e.g., dial-a-ride) across the country2.

The Rural Passenger Transportation Technical Assistance Program (RPTTAP) and the Tribal Passenger Transportation Technical Assistance Program (TPTTAP) provide technical assistance to small communities to create and improve rural and tribal public transportation24. These programs were created by the U.S. Department of Agriculture (USDA) and are administered by the Community Transportation Association of America24.

The U.S. Department of Veterans Affairs (U.S. VA) offers Highly Rural Transportation Grants to state Veterans Service agencies to transport veterans living in highly rural areas (i.e., fewer than seven people per square mile) to U.S. VA health care facilities in eligible counties25.

Some state government agencies have established vanpools to transport rural residents to employment opportunities in rural and urban areas; California and Wisconsin are two examples26, 27.

Non-profit organizations may also offer transportation services and support for rural communities. Established in 2018, Feonix-Mobility Rising partners with local communities to create transportation assistance hubs, which act as a safety net for mobility by offering free and low cost rides through networks of volunteer drivers, demand-response services, and public transit. Feonix has active hubs in Michigan, Mississippi, Nevada, South Carolina, Texas, and Wisconsin and offers online accessibility and disability awareness training for transportation professionals to support the needs of individuals with disabilities28.

Implementation Resources

Resources with a focus on equity.

SGA-Thakkar 2023 - Thakkar A, Smith JR, Bellis R, et al. An active roadmap: Best practices in rural mobility. Smart Growth America (SGA) and National Complete Streets Coalition. 2023.

RHIhub-Transportation - Rural Health Information Hub (RHIhub). Transportation to support rural healthcare.

RHIhub-Transportation toolkit - Rural Health Information Hub (RHIhub). Rural transportation toolkit.

National RTAP - National Rural Transit Assistance Program (National RTAP). History of National RTAP.

National RTAP-State toolkit - National Rural Transit Assistance Program (National RTAP). State RTAP manager’s toolkit.

NDSU-Mattson 2022 - Mattson J, Mistry D. Rural transit fact book, 2022. Fargo: North Dakota State University (NDSU), Upper Great Plains Transportation Institute, Small Urban and Rural Center on Mobility; 2022.

APTA-Resources - American Public Transportation Association (APTA). Research and technical resources.


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1 US DOT-Rural transportation - U.S. Department of Transportation (U.S. DOT). Transportation and health tool: Rural public transportation systems. 2019.

2 NDSU-Mattson 2022 - Mattson J, Mistry D. Rural transit fact book, 2022. Fargo: North Dakota State University (NDSU), Upper Great Plains Transportation Institute, Small Urban and Rural Center on Mobility; 2022.

3 National RTAP - National Rural Transit Assistance Program (National RTAP). History of National RTAP.

4 RHIhub-Transportation - Rural Health Information Hub (RHIhub). Transportation to support rural healthcare.

5 Mattson 2021 - Mattson J, Peterson D. Measuring benefits of rural and small urban transit in Greater Minnesota. Transportation Research Record. 2021;2675(5):356-366.

6 Marr 2015 - Marr EJ. Assessing transportation disadvantage in rural Ontario, Canada: A case study of Huron County. Journal of Rural and Community Development. 2015;10(2):100-120.

7 Yang 2017 - Yang H, Cherry CR. Use characteristics and demographics of rural transit riders: A case study in Tennessee. Transportation Planning and Technology. 2017;40(2):213-227.

8 Bond 2017 - Bond M, Brown JR, Wood J. Adapting to challenge: Examining older adult transportation in rural communities. Case Studies on Transport Policy. 2017.

9 Henning-Smith 2018 - Henning-Smith C, Evenson A, Kozhimannil K, Moscovice I. Geographic variation in transportation concerns and adaptations to travel-limiting health conditions in the United States. Journal of Transport and Health. 2018;8:137-145.

10 Shirgaokar 2020 - Shirgaokar M, Dobbs B, Anderson L, Hussey E. Do rural older adults take fewer trips than their urban counterparts for lack of a ride? Journal of Transport Geography. 2020;87:102819.

11 Pike 2018 - Pike S, Rodier C, Martinez J. The potential for shared use mobility in affordable housing complexes in rural California. Davis: University of California Institute of Transportation Studies; 2018.

12 Choi 2019a - Choi M, Schuster AM, Schoenberg NE. Solutions to the challenge of meeting rural transportation needs: Middle-aged and older adults’ perspectives. Journal of Gerontological Social Work. 2019;62(4):415-431.

13 Zhang 2022 - Zhang Y, Xu D. The bus is arriving: Population growth and public transportation ridership in rural America. Journal of Rural Studies. 2022;95:467-474.

14 Israel Schwarzlose 2014 - Israel Schwarzlose AA, Mjelde JW, Dudensing RM, et al. Willingness to pay for public transportation options for improving the quality of life of the rural elderly. Transportation Research Part A: Policy and Practice. 2014;61:1-14.

15 Dize 2019 - Dize V. Getting around in rural America. Generations. 2019;43(2):33-39.

16 Thakuriah 2011b - Thakuriah (Vonu) P. Variations in employment transportation outcomes: Role of site-level factors. Papers Regional Science. 2011;90(4):755-772.

17 Thakuriah 2013 - Thakuriah (Vonu) P, Persky J, Soot S, Sriraj PS. Costs and benefits of employment transportation for low-wage workers: An assessment of job access public transportation services. Evaluation and Program Planning. 2013;37:31-42.

18 Peng 1998 - Peng ZR, Nelson AC. Rural transit services: A local economic and fiscal impact analysis. Transportation Research Record: Journal of the Transportation Research Board. 1998;(1623):57-62.

19 Stommes 2005 - Stommes ES, Brown DM. Moving rural residents to work. Transportation Research Record: Journal of the Transportation Research Board. 2005;(1903):45-53.

20 TRB-Ellis 2009 - Ellis E, McCollom B. TCRP Report 136. Guidebook for rural demand-response transportation: Measuring, assessing, and improving performance. Washington, D.C.: Transportation Research Board (TRB); 2009.

21 Mishra 2018 - Mishra S, Cherry CR, Golias MM, et al. Assessment of mobility and transit access to captive riders in suburban and rural areas. Memphis: University of Memphis; Tennessee Department of Transportation; 2018.

22 Godavarthy 2015 - Godavarthy RP, Mattson J, Ndembe E. Cost-benefit analysis of rural and small urban transit in the United States. Transportation Research Record: Journal of the Transportation Research Board. 2015;2533:141-148.

23 US DOT-Section 5311 - U.S. Department of Transportation (U.S. DOT). Fact sheet: Formula grants for rural areas, section 5311. 2012.

24 CTAA-Rural - Community Transportation Association of America (CTAA). Summary: Rural & tribal passenger transportation technical assistance through CTAA.

25 US VA-HRTG - U.S. Department of Veterans Affairs (U.S. VA). Health care: Highly Rural Transportation Grants (HRTG).

26 CalVans - California Vanpool Authority (CalVans). California’s single source for ridesharing to work or college in a CalVans vehicle.

27 WI DOA-Vanpool - Wisconsin Department of Administration (WI DOA). Joining a vanpool.

28 Feonix - Feonix-Mobility Rising. Transportation assistance hub.

29 AHA-Harrington 2020 - Harrington RA, Califf RM, Balamurugan A, et al. Call to action: Rural health: A presidential advisory from the American Heart Association and American Stroke Association. Circulation. 2020;141(10):e615-e644.

30 NASEM-Thomas 2022 - Thomas DN, Heer N, Wyatt Mitchell I, et al. Racial equity, Black America, and public transportation, volume 1: A review of economic, health, and social impacts. Washington, D.C.: National Academies Press; 2022.

31 Tehrani 2019 - Tehrani SO, Wu SJ, Roberts JD. The color of health: Residential segregation, light rail transit developments, and gentrification in the United States. International Journal of Environmental Research and Public Health. 2019;16(19):3683.

32 Schauer 2003 - Schauer P. The trip to town: Rural transportation patterns and developments since 1900. Transportation Research Board (TRB): TR News. 2003;225:4-11.

33 National Interstate Act 1956 - The U.S. National Archives and Records Administration. Milestone documents: National Interstate and Defense Highways Act (1956).

34 McDaniels 2018 - McDaniels BW, Harley DA, Beach DT. Transportation, accessibility, and accommodation in rural communities. In: Harley DA, Ysasi N, Bishop M, Fleming A, eds. Disability and Vocational Rehabilitation in Rural Settings. Cham: Springer International Publishing; 2018:43-57.

35 SGA-Thakkar 2023 - Thakkar A, Smith JR, Bellis R, et al. An active roadmap: Best practices in rural mobility. Smart Growth America (SGA) and National Complete Streets Coalition. 2023.

36 US DOT-FTA-NTD History - U.S. Department of Transportation (U.S. DOT), Federal Transit Administration (FTA). History of the National Transit Database (NTD) and transit in the United States. 2017.

Date Last Updated