As lawmakers prepare for a showdown over health insurance legislation, a new report finds that for rural Americans, a lack of coverage is just one of many reasons they are more vulnerable to early death than their urban counterparts.

While the top five causes of death were the same for all Americans from 1999 to 2014—heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke—they were more likely to kill the 15 percent of Americans living in rural areas than their urban counterparts, according to research from the Centers for Disease Control and Prevention. “This new study shows there is a striking gap in health between rural and urban Americans,” said CDC Director Tom Frieden.

The difference can be attributed to a confluence of environmental, economic, and social factors, including smoking rates, opioid use, poverty levels, poor nutrition, levels of physical activity, and access to health care, according to the CDC. Solving these problems requires better access to public health and health care services, said Alana Knudson, co-director of the NORC Walsh Center for Rural Analysis. Both "require financial resources," she said, to lower the mortality rate.

For example, unintentional injury death rates are 50 percent higher in rural areas than urban areas, in part a result of more high-speed motor vehicle traffic-related deaths. But once a person is in an accident in a rural setting, they are also less likely to receive prompt medical attention. Geographical distances make it take ambulances longer to arrive; once they do, a trauma center is less likely be near. Only 11 percent of all doctors practice in rural areas of the country, the CDC noted.

Rural dwellers are also less likely to have access to health insurance through employment, according to a 2014 report (PDF) from the Henry J. Kaiser Family Foundation. From 2012 to 2013, 51 percent of the U.S. rural population had employer-sponsored insurance coverage, compared to 57 percent of the metropolitan population. While the Affordable Care Act targeted uninsured individuals with low-to-moderate incomes—who are more likely to live in rural areas—many states chose not to expand Medicaid coverage under the ACA. Nearly two-thirds of rural Americans uninsured in 2014 lived in one of the 24 states not implementing Medicaid coverage. (That number has since dropped to 19 states.)

President-elect Donald Trump has promised to repeal the ACA, which the CDC doesn't consider a cure-all in any event. "Focusing on access to health care in rural areas of the United States alone is not sufficient to adequately address complex health outcomes," the report concluded. Different causes of death require different solutions, and the report offers a number of suggestions, including more substance abuse services, more cancer screening programs, and the enforcement of seatbelt and drunk driving laws. Better health insurance certainly couldn't hurt.