The health impact pyramid offers a framework for considering the relative significance of socioeconomic determinants of health and for prioritizing interventions that may be effective in improving health outcomes in hard-to-reach and rural populations. Barriers to health care delivery in rural settings are outlined with examples provided. Demonstration projects in East and West Texas are reviewed. Those programs reach unique populations such as agricultural and migrant workers and those with mental illness by using innovative approaches, such as the use of specially trained community health workers and telehealth and telemedicine. Having a health impact on hard-to-reach groups and rural populations is largely a function of overcoming numerous barriers. Adopting a population health approach that engages the community in overcoming those barriers is likely to be more effective in producing improved health outcomes.