Rural areas have greater health needs than urban poor
Rural areas have greater health needs than urban poor
As responsibility for health care programs continues to devolve from the federal government to the states, it is important for state governments to understand the health characteristics of their particular mix of rural and urban areas. Most relevant national data, however, do not allow for intrastate analysis. Recently, the Urban Institute in Washington, DC, as part of its study "Assessing the New Federalism," issued a report on rural/urban differences in health care based on the Institute’s National Survey of America’s Families, a survey of children and adults under age 65 in more than 44,000 households.
Of the 13 states examined in the new federalism study, eight have substantial rural populations: Alabama, Colorado, Michigan, Minnesota, Mississippi, Texas, Washington, and Wisconsin. The health care analysis presents data for three types of geographic areas — urban, rural adjacent (contiguous to a metropolitan area), and rural nonadjacent.
In 1997, 20.4% of the nation’s population lived in rural areas. Mississippi was by far the most rural of the study states, with 69.5% of its population living in rural areas. Alabama and Wisconsin were the next most rural, each with about one-third of its population in rural counties.
When researchers examined the specific features of the rural areas in each state, however, they discovered widely varied situations, making the case for individualized state health care solutions. For example, Mississippi’s rural population is concentrated in areas far from urban influence, with 53.7% of Mississippians living in nonadjacent counties. Minnesota and Colorado had smaller total proportions of their population in rural areas, but with 18.3% and 15.5% of their populations in nonadjacent counties; these rural populations were more isolated than those of Alabama and Wisconsin.
"The inconsistency across states and in comparison with the national numbers was the most surprising thing we saw," says Barbara Ormond, a research associate in the Urban Institute’s Health Policy Center. "There’s a state story going on that is much more important than the national story. And circumstances in each state are different because of population demographics and health care system differences."
Ms. Ormond says that because each state tries to assess gaps in health care coverage and address them as best it can, the numbers for each state can indicate what the state believed its original priorities were. But, she added, "If you emphasize one issue, others can lag behind."
Income has been shown to be correlated with many health status and access characteristics studied, and the family study data show that rural areas are poorer than urban areas; the more isolated the rural area, the greater the degree of poverty. Nationally, 13.8% of the urban population in 1997 was poor (household income below 100% of the federal poverty level), but the proportion rose to 15.8% in adjacent areas and 22.5% in nonadjacent areas.
The proportion of the nonelderly covered by private health insurance (primarily employer-sponsored) falls where county of residence is more remote. While 74.6% of urban residents had private insurance, only 71.5% of residents in adjacent counties and 62.6% of those in nonadjacent counties had such coverage. One reason for the reduction of employer-sponsored coverage in nonadjacent areas is their greater prevalence of small businesses, lower wages, and self-employment.
To some extent, the shortfall in private coverage in nonadjacent areas is offset by higher rates of public coverage, but there still is enough of a gap that 21.9% of residents in nonadjacent areas were uninsured, compared with 14.3% in urban areas.
While lower insurance rates might not pose as much of a problem if rural residents were less likely to need health care services, the data show that nationally the reported health status of rural residents, especially those in nonadjacent areas, seems to be worse than that of urban residents. State-level differences do not closely track the national figures, again making the case for individual state analyses and response. In four of the eight predominantly rural counties studied, there were no significant differences between urban and rural areas in the share of the population in fair or poor health.
And, despite poorer health status, rural residents get less medical attention than those in urban areas. Differences in health care utilization would be even more pronounced except for the fact that nonphysician providers play a larger role in rural health care.
Given a higher implied need for health services and lower utilization rates, it makes sense that rural residents say they are less confident about access to health care services than those in urban communities.
Stephen Zuckerman, a principal research associate at the institute, says that the significance of the study is that as states are given more responsibility for health policy by the federal government, they need to "recognize that a uniform policy may not work. They’re going to have to tailor policy to the needs of various areas of their states."
Ms. Ormond says it also is important to remember the role that the private sector plays in driving health system change. For instance, the structure of the private insurance market drives a lot of system change. "[And] as managed care comes in, there is an increased demand for primary care physicians and greater competition for them. This can have a detrimental effect in rural areas that historically have been more able to attract specialists."
Ms. Ormond and Mr. Zuckerman say they are now doing additional work with the data to use multivariate analysis to separate the influence of income and insurance status.
They say a key policy implication of the study to date is the need for flexibility in federal funding to match the very different picture that is seen from state to state. While there are "healthy communities" movements gaining support for the idea of design of locally responsive health care systems, the two caution that there can be problems when people in rural areas are adamant about maintaining local control over health care. "There’s a concern that each community would want its own high-tech equipment and hospital. The reality is that some things can be done better at the regional level. There is a tension between local control and efficiency through regionalization."
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