This paper explores the unintended consequences of health policy through an analysis of policy actions that have affected, or had the potential to affect, rural people, places, and/or providers in ways counteractive to policy intent. Two realities drive the need for this analysis: (1) rural healthcare systems are living with the legacy of policies having unintended consequences because the full impact of such policies on rural stakeholders was neither predicted nor understood, and (2) because policymakers have recognized the need to apply a rural lens to new and ongoing programs and policies to inform the pathways by which equitable rural health status and healthcare can be achieved. We conclude the paper with a framework for health policy evaluation that considers potential and unintended rural impacts.