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RURAL HEALTH DISPARITIES An Overview for State Policymakers
Online Tutorial
Summer 2013
Joshua Ewing, Policy Specialist
NCSL Health Program, Denver Colorado
What is Rural?
• Multiple Definitions
• U. S. Census Bureau
– “Rural” encompasses all population, housing, and territory not included within an urban area. Whatever is not urban is considered rural.
Source: HRSA Office of Rural Health Policy, 2013
What is Rural?
• Multiple Definitions
• Office of Management and Budget – OMB designates counties as Metropolitan,
Micropolitan, or Neither. A Metro area contains a core urban area of 50,000 or more people. All counties that are not part of a Metropolitan Statistical Area (MSA) are considered rural.
Source: HRSA Office of Rural Health Policy, 2013
What is Rural?
• Approximately 51 million (1 in 6) people live in rural and frontier areas of the country
• Despite only comprising 16 percent of the U.S. population, rural Americans reside in 75 percent of the total U.S. land area.
Source: Cromartie, 2012
Health Disparities Defined
• Population-specific differences in the presence of disease, health outcomes, quality of health care and access to health care services as compared to the health status of the general population.
Health Status
• Mortality
• Disability
• Chronic Disease
Mortality Rates
• The overall age-adjusted death rate per 100,000 people is declining in all areas of the country.
• The mortality rate remains higher in rural areas, particularly for males.
Source: CDC, 2013
Health Status
• Mortality
• Disability
• Chronic Disease
Disability Rates
• The rate of people living with a complex activity limitation--defined as having one or more of the following limitations: self-care (activities of daily living or instrumental activities of daily living), social, or work--is higher in rural areas.
Source: CDC, 2013
Complex Activity Limitations by Metropolitan Statistical Area
Source: CDC, 2013
0
5
10
15
20
25
30
35
40
45
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Pe
rce
nt
of
Po
pu
lati
on
Year
Inside MSA
Outside MSA
Health Status
• Mortality
• Disability
• Chronic Disease
Chronic Disease
• Rural residents report higher rates of heart disease, cancer and stroke than their urban counterparts.
Source: CDC, 2013
Heart Disease by Metropolitan Statistical Area
0
2
4
6
8
10
12
14
16
05-06 07-08 08-09 09-10 10-11
Pe
rce
nt
of
Po
pu
lati
on
Year
Within MSA
Outside MSA
Source: CDC, 2013
Cancer Rates by Metropolitan Statistical Area
0
1
2
3
4
5
6
7
8
05-06 07-08 08-09 09-10 10-11
Pe
rce
nt
of
Po
pu
lati
on
Year
Within MSA
Outside MSA
Source: CDC, 2013
Stroke Rates by Metropolitan Statistical Area
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
05-06 07-08 08-09 09-10 10-11
Pe
rce
nt
of
Po
pu
lati
on
Year
Within MSA
Outside MSA
Source: CDC, 2013
Risk Factors • Rural residents
are also more likely to smoke, be obese, and fail to exercise.
Source: Jones, C., Parker, T., Ahearn, M., Mishra, A. K., & Variyam, J. (2009)
Contributing Factors
• Poverty Rate
• Education Attainment
• Aging Population and Health Care Workforce
• Health Insurance Coverage
• Access to Health Care Services
Contributing Factors- Poverty
• In 2011, the poverty rate grew to 17.0 percent of the rural population nationally, while the rate decreased in metropolitan areas to 14.6 percent of people living there.
• This difference is most pronounced in the southern region of the country.
Source: USDA Economic Research Service, 2013
Poverty Rates by Region and Residence, 2011
13.4% 14.4%
20.1%
16.6% 13.3% 13.0%
16.0% 15.4%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Northeast Midwest South West
Nonmetro
Metro
Source: USDA Economic Research Service using data from the U.S. Census Bureau's 2012 Current Population Survey, March Supplement.
Contributing Factors
• Poverty
• Education Attainment
• Aging Population and Health Care Workforce
• Health Insurance Coverage
• Access to Health Care Services
Contributing Factors- Education
• Rural rates of high school completion, college attendance, and college completion all rose during the 2000s.
• However, the gap in adults with a bachelor’s degree or higher continues to grow wider—17.4 percent of people in rural areas versus 30.2 percent of people in metro areas in 2007-11.
Source: USDA Economic Research Service, 2013
Contributing Factors- Education
Source: USDA Economic Research Service, 2013
Contributing Factors
• Poverty
• Education Attainment
• Aging Population and Health Care Workforce
• Health Insurance Coverage
• Access to Health Care Services
Contributing Factors- Aging Population
• The rate of growth for seniors living in rural areas has tripled since the 1990s, and if the 80 million baby boomers living in the United States continue to follow these migration patterns, the rural population of those age 55 to 75 is set to increase 30 percent between 2010 and 2020.
Source: Cromartie & Nelson, 2009
Source: USDA Economic Research Service, 2013
Percent of Population 65 or Older, 2010
Contributing Factors- Aging Population
• The number of new primary care practitioners entering the workforce is well below the current replacement rate for retiring primary care practitioners. This is likely to exacerbate existing shortages unless more practitioners can be recruited to rural areas.
Source: Cromartie & Nelson, 2009
Contributing Factors
• Poverty Rate
• Education Attainment
• Aging Population and Health Care Workforce
• Health Insurance Coverage
• Access to Health Care Services
Contributing Factors- Health Insurance
• People living in rural areas are more likely to be uninsured, or receive health insurance coverage through public programs than their urban counterparts.
Source: Agency for Healthcare Research and Quality, 2012
Health Insurance Coverage- 2012
58.5%
23.1% 18.4%
47.7%
31.7%
20.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Private Public Uninsured
Metro
Non Metro
Source: Agency for Healthcare Research and Quality, 2012
Contributing Factors
• Poverty Rate
• Education Attainment
• Aging Population and Health Care Workforce
• Health Insurance Coverage
• Access to Health Care Services
Contributing Factors- Access
• Nearly 20 percent of the nation’s population live in rural areas, however, only about 11 percent of physicians practice there.
• While nearly 85 percent of U.S. residents can reach a Level I or Level II trauma center within an hour, only 24 percent of residents living in rural areas can do so within that time frame – this likely contributes to the fact that 60 percent of all trauma deaths in the United States occur in rural areas.
Sources: Cromartie, 2012; Branas, C. C., MacKenzie, E. J., Williams, J. C., Schwab, C. W., Teter, H. M., Flanigan, M. C., et al. (2005).
More Information
• Visit www.ncsl.org and search "rural health"
• Email [email protected]
• Call 303-364-7700 and ask to speak with someone in the health program
SPECIAL THANKS TO THE FEDERAL OFFICE OF RURAL HEALTH POLICY (ORHP).
ORHP coordinates activities related to rural health care within the U.S. Department of Health and Human Services. Part of the
Health Resources and Services Administration (HRSA), ORHP has department-wide responsibility for analyzing the possible
effects of policy on 62 million residents of rural communities. Created by Section 711 of the Social Security Act,
ORHP advises the Secretary on health issues within these communities, including the effects of Medicare and Medicaid on rural citizens’ access to care, the viability of rural hospitals,
and the availability of physicians and other health professionals.
This tutorial was made possible by grant number UD3OA22893 from the Health Resources and Services Administration. Its contents are solely the responsibility of the author and do not necessarily represent the official views of the HRSA.
National Conference of State Legislatures
William T. Pound, Executive Director
7700 East First Place
Denver, Colorado 80230
(303) 364-7700
444 North Capitol Street, N.W., #515
Washington, D.C. 20001
(202) 624-5400
www.ncsl.org
© 2013 by the National Conference of State Legislatures. All rights reserved.