Prior to the early 20th century, rural residents often had greater health than urban residents. However, there is currently ample evidence of a significant rural health disadvantage and health insurance for people living in urban areas. Although there are many potential causes for this shift in the rural-urban health gap, uneven access to medical treatment is frequently considered to be one of them.
In this Statistical Brief, newvehiclez.com examined three key indicators of ambulatory care access across the Rural-Urban Continuum Codes developed by the United States Department of Agriculture (USDA) by pooling data from the Medical Expenditure Panel Survey Household Component (MEPS-HC) for the years 2014 and 2015.
These indicators were the percentage of people without insurance, the percentage without a regular source of care, and the percentage reporting unmet need for medical care, dental care, or prescription drugs. All differences mentioned in the text are statistically significant at the 0.05 level or higher, unless otherwise stated.
Three metropolitan (metro) and six nonmetropolitan (non-metro) categories are used by the Rural-Urban Continuum Codes to categorize counties. According to the population of respective metro areas (more than 1 million, between 250,000 and 1 million, and less than 250,000), metro counties are divided into the three conventional divisions in this brief.
Based on their proximity to a metro county (i.e., “adjacent” versus “non-adjacent” counties1) and two groupings of urban population size (counties with urban populations of 20,000 people or more and those with fewer than 20,000), non-metro counties are divided into four categories.
Highlights – Health insurance for people living in urban areas
- In 2014–2015, there was no difference in the percentage of people under 65 without insurance between metro and non-metro populations. However, compared to metro residents, non-metro inhabitants were less likely to have private insurance and more likely to have public insurance.
- When comparing residents of the three metro groups to those of the two non-metro categories, the percentage of those 65 and older who rely only on Medicare, as opposed to Medicare with some private supplemental coverage, was greater.
- Non-metro people were less likely than metro residents, among those under 65, to lack a regular provider of care. In both urban and non-metro areas, the percentage of people 65 and older without a regular source of care was comparable.
- The percentage of people reporting unmet needs for medical, dental, or prescription medication care varied little over the rural-urban continuum. Non-metro inhabitants were less likely to report unmet need than metro residents when differences were statistically significant.
Findings – Health insurance for people living in urban areas
Residents of metro and non-metro counties had comparable overall percentages of those under 65 without health insurance for people living in urban areas coverage in 2014–2015 (figure 1a). However, there were differences in the percentage of metro and non-metro inhabitants who had either private or state insurance. Overall, non-metro residents were more likely to have public insurance (27 versus 21%) and were less likely to have private insurance (62 versus 69%) than metro people. With less than 20,000 urban residents, non-adjacent counties had residents with the greatest rate of public coverage (32 percent).
The percentage of people 65 and older with only Medicare coverage, Medicare plus private coverage, or Medicare plus other public coverage did not differ statistically significantly between metro and non-metro inhabitants (figure 1b). However, there were a number of statistically significant variations across the categories throughout the continuum between rural and urban areas.
These show that fewer people in non-adjacent counties than those in metro areas have private supplemental insurance in addition to Medicare. For instance, only 42–43% of people aged 65 and older who lived in non-adjacent counties received private supplemental coverage, compared to 60% of those in medium-sized metro counties (between 250,000 and 1 million population).
Under-65 metro inhabitants were more likely than non-metro residents to lack a regular source of care (25 versus 19%) (figure 2a). With the exception of the sizable non-adjacent counties (25%) in all pair-wise comparisons of the rural-urban continuum groups, the non-metro advantage is generally present. There were no statistically significant variations in the percentage of those 65 and older without a customary provider of care between metro and non-metro residents (figure 2b).
Overall, 10 percent of non-metro residents under 65 were just as likely as their metro counterparts to report having unmet needs for medical care, dental care, or prescription medications (figure 3a). With one exception, there were few differences between the categories of the rural-urban continuum: inhabitants of small metro counties (under 250,000 people) were significantly more likely to report unmet need than inhabitants of non-adjacent counties with urban populations greater than 20,000 (11 versus 8 percent).
People 65 and older have a similar pattern of unmet demand (figure 3b). Overall, the percentage of elderly people with unmet needs did not differ statistically significantly between metro and non-metro areas, but people living in non-adjacent counties with urban populations greater than 20,000 were significantly less likely to report unmet need than people living in the two smallest metro counties (8 versus 15 and 14 percent).
It is significant to note that residents of metro areas and non-metro areas differ in a number of socioeconomic and demographic factors (tables 1a and 1b), which are closely related to insurance and healthcare access. Having a regular source of care and reporting an unmet need for medical, dental, or prescription drugs are two other key indicators of ambulatory care access that may not be comparable across the full rural-urban continuum.