Healthcare disparities by level of rurality

Introduction: Healthcare is a key determinant of health, and access to healthcare has been deemed the top rural health priority. Moreover, residents of rural areas have been designated a priority population for the nation's on-going efforts to eliminate health disparities. Although over 20% of the U.S. population lives in rural areas (i.e. population < 2,500), few health data sources identify respondents by rural residence. Fortunately, there are health data sources that identify respondents by county of residence and permit distinguishing metropolitan from non-metropolitan counties, the latter serving as a proxy for rural residence. Using this proxy, we examine the rural burden of healthcare disparities by disaggregating levels of rurality. Methods: We used data for U.S. adults, 18 years and older, from the 2009 Behavioral Risk Factor Surveillance System (BRFSS), and data for U.S. counties from the 2009-2010 Area Resource File (ARF). We classified county of residence using the categories 1) Metropolitan, 2) Micropolitan, 3) Noncore adjacent to metro, and 4) Noncore remote by collapsing the 12 categories of the 2003 Urban Influence Codes. Outcomes include insurance coverage, usual provider, preventive care in the past year, and foregone care due to cost. We used cross-tabulations with design-based f-tests to examine disparities by level of rurality. We then used logistic regression to estimate the odds of poor access by level of rurality adjusting for sociodemographic characteristics. Finally, we stratified by rurality and examined race/ethnic disparities within each level. Results: Over 70% of U.S. counties are represented in the BRFSS data, but representation declines by level of rurality. Moreover, respondents are significantly different on all sociodemographic characteristics by level of rurality. Compared with metropolitan residents, those living in any of the three levels of rurality have significantly higher odds of being uninsured, no past year preventive care and foregone care even after covariate adjustment. Within levels of rurality, there are significant racial/ethnic disparities in all outcomes. Discussion: One of the principal goals of the Affordable Care Act (ACA) is to reduce health disparities in low-income, minority and other populations. To assess the success (or failure) in meeting this goal requires valid, reliable data about both urban and rural populations. At present, information about healthcare access and quality for rural residents is limited. Our study begins to address the limitations of current data and analyses, permitting establishment of baseline measures needed in any assessment of the ACA's success in reducing disparities.