This paper analyzes the ability of rural communities to maintain health care services for their residents in a changing health care environment. In addition to the constantly evolving health care marketplace, factors that influence the structure and strength of the rural health care safety net include demography, geography, and policies at the federal, state, and local levels. The safety net in rural areas generally includes almost all local providers. Therefore, maintaining the safety net in rural communities strengthens the entire health care infrastructure. The study describes the health care safety net in 11 rural counties in five states (AL, MN, MS, TX, and WA).