One indicator of the general economic health of a region is the rate at which new jobs are created. The newly developed Longitudinal Business Database has been used in this paper to develop a detailed portrait of establishment formation and attrition and job creation and destruction in the Appalachian Region. The foremost finding is that the pace of reallocation in Appalachia is lower than it is for the U.S.. This is evident in Appalachia’s relatively lower establishment birth and death rates and job creation and destruction rates. For example, on average over the study time period, the U.S. job creation rate exceeds 45 percent, while the Appalachian job creation rate is 43 percent. Similarly, the U.S. job destruction rate is about 35 percent, while the Appalachian job destruction rate is about 33 percent. Even when controlling for other differences, job creation rates are 1.2 percentage points lower and job destruction rates are 3.4 percentage points lower in Appalachia relative to the rest of the U.S. Another indicator of the general economic health of a region is the quality of its jobs. The quality of jobs is measured in this paper by the average wage paid at the establishment. Here too there is cause for concern about the economic health of Appalachia. The analysis shows that wages are about 10 percent lower in Appalachia than in the U.S. even when controlling for differences in other characteristics across the two areas. This wage discrepancy has not narrowed over the time of the study. Moreover, new establishments have a similar wage gap. Employees at new establishments earn wages 10 percent less than at new establishments in the rest of the U.S.