Rural voices. Three states.
One urgent story.
This report was developed to elevate the lived experiences of rural older adults — particularly those dually eligible for Medicare and Medicaid — and translate those experiences into practical insights for policy and systems change. Click any portrait to read their story.
These interviews were conducted in collaboration with The People Say, an online research platform that features first-hand insights from older adults on the issues most important to them. Sixteen interviews were conducted as part of this project and added to The People Say's growing database, helping to inform the development of policies, systems, and programs that more accurately reflect the needs, preferences, and realities of older adults.
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"Where I live now, I thought something would be there. There is no coordinator. We have no coordinator. It's all up to us to manage our own events."
"I just wish our county would get some better senior housing and make these kinds of facilities available to the older population. I'm beginning to think my age group — and this is a moral question — how much do you value people of my age? Are we really someone of value? Do you value them enough to help them during an emergency situation or to give them the advantage of going someplace?"
"I'm able to receive the Friendly Visiting program through Lutheran Social Services. I'm kind of a private person, and I'm not real forthright in trying to find friends or reaching out, and so this has been nice. She's a lovely lady, and she's been willing to do things with me."
"[Without Medicaid and my housing] I'd be lost. I just wouldn't know what to do. If I got sick, I don't know where to go. I would just be out. I wouldn't know what to do 'cause I've been doing this for three years. I got adapted to it and I know what to do now. If I ever lost it, I'd be in a hole."
"The distance to care is real. When you live 40 miles from the nearest clinic, a routine appointment takes half a day — and that's before you factor in transportation."
"The paperwork never ends. I fill out the same information year after year just to prove I still qualify for the same benefits. It feels like the system is designed to make you give up."
"Right now, I don't have car. I can walk anywhere I want to go. I don't even have the money to buy car. [To go to the doctor] I sometimes ride bus to get there. They say, 'Where is Medicaid?...' You can use it for transportation, but I don't know how to use it. I don't know how to use it to call taxi or to get it."
"My case worker who does all this [re-certifying social security, other paperwork] thing for me. Medicaid. Now when they cut my food stamp, she can work to put it back. Medicare, they cut it. She work to put it back.... Oh, she help me with everything. Everything they've taken from me, she will make sure to put it back there.... Without her, everything is blunt to me. I don't know the procedure. I don't know where to go. She the one I'm depending on."
"Everything is so far away. The nearest place that takes my insurance is over an hour drive. On a good day that's manageable. In winter, it's a different story entirely."
"The only thing I'm lacking as far as assistance from Medicaid and Medicare is my vision, my hearing, and my teeth. I've got eight teeth in my mouth, and I've pulled every one of my own teeth because insurance just don't cover it, and it should. There's no two ways around that. Medicare should step up to the plate and take care of that for elderly people. 'Cause I've worked hard in my life, and I paid into it, and I feel I should have those big benefits."
"Without Medicaid and other programs I'd be homeless."
"My dad, he's worked hard all of his life. There's a lot of farmers out there that, when it comes to retirement, they don't end up with a whole lot. There's not just him out there. I know a lot of 'em, elderly people that are just barely getting by. If it wasn't for the Medicaid or the Medicare, they would totally be homeless or they would just die because they wouldn't have the money for medication."
"[My case worker] has been heaven-sent on [re-applying] because that's how I got in with her was I didn't know what I was doing. I was getting things in the mail, and I didn't know what to do with them.... She's been a really, really awesome help for me, not just for my dad, but for myself, too.... How did I meet her? I think through Lutheran Social Services."
Partnership and Approach
A collaborative effort to amplify voices often absent from policy discussions.
Who We Are
This report reflects a collaborative partnership among Lutheran Services in America (LSA), The SCAN Foundation (TSF), and Public Policy Lab's The People Say (PPL/TPS) — organizations united by a shared commitment to advancing equity, strengthening community-based systems of care, and ensuring that older adults can age with dignity and security, regardless of where they live.
LSA brings the reach and deep community relationships of its national network across rural Minnesota, North Dakota, and South Dakota. TSF contributes decades of leadership in aging policy and innovation, while PPL/TPS provides expertise in human-centered research and participatory design.
Why Dual-Eligible People
The focus on individuals dually eligible for Medicare and Medicaid reflects the complexity created by two separate programs and the importance of better coordinating care across systems. Dual-eligible older adults frequently have the greatest health, functional, and social needs, while also navigating the most complicated coverage rules and administrative requirements.1
At the same time, older adults serve as anchors in many communities — sharing wisdom, caregiving for neighbors and family, and sustaining the social fabric that rural communities depend on. In rural areas, these challenges are intensified by limited provider availability, long travel distances, workforce shortages, and inconsistent access to transportation, broadband, and trusted navigation support.
1 Roberts ET, Johnston KJ, Figueroa JF. Integrating Medicare and Medicaid Coverage for Dual Eligibles—Recommendations for Reform. JAMA. 2023 Aug 1;330(5):409–410. doi: 10.1001/jama.2023.8879. PMID: 37440224; PMCID: PMC11875113.
Across Minnesota, North Dakota, and South Dakota, participants in this study described a daily reality shaped by these intersecting challenges — where accessing basic healthcare, maintaining independence, and remaining connected to their communities often requires extraordinary persistence and resilience. Their experiences illuminate not only the gaps within current systems, but also the opportunities for targeted, community-driven solutions. By centering these lived experiences alongside quantitative data, this report offers a more complete understanding of rural aging realities and provides a foundation for policy and practice recommendations that are grounded in both evidence and the human lived experience.
