For a lot of people, "45 minutes by car to get to a city of any real size" is very much in the middle of nowhere.
Honestly, Americans are probably more tolerant and accepting of long distances compared to most peer countries. 45 minutes of driving to hit some kind of city is very far most of the time in Japan or most of Europe, where the population density is higher than the states.
It’s amazing how perspective changes. If you haven’t experienced it I suspect it’s impossible to understand, because this feels crazy to write. It’s true though.
However, the proportion of people who live like that is not very high. People mostly live where other people live.