Growing up in a rural setting is a strong predictor of future rural practice for physicians. This study reports on the fifteen-year decline in the number of rural medical students, culminating in rural students' representing less than 5 percent of all incoming medical students in 2017. Furthermore, students from underrepresented racial/ethnic minority groups in medicine (URM) with rural backgrounds made up less than 0.5 percent of new medical students in 2017. Both URM and non-URM students with rural backgrounds are substantially and increasingly underrepresented in medical school. If the number of rural students entering medical school were to become proportional to the share of rural residents in the US population, the number would have to quadruple. To date, medical schools' efforts to recognize and value a rural background have been insufficient to stem the decline in the number of rural medical students. Policy makers and other stakeholders should recognize the exacerbated risk to rural access created by this trend. Efforts to reinforce the rural pipeline into medicine warrant further investment and ongoing evaluation.