An Access to Care Model Illustrating Individual and Community-Level Predictors between Urban and Rural Populations

Significant social and individual determinants in access to healthcare exists among rural communities. This study presents the results of a study using hierarchical modeling to understand access to healthcare among rural and urban communities in East-Central Texas. This study used data from a 2013 population health status assessment survey collected in nine Texas counties. Seven counties are non-metropolitan, rural communities who are traditionally underserved and receive less than adequate health and social service resources. The proposed access to care model includes individual characteristics, barriers to accessing health care such as out-of-pocket expense, missed work, and health status, as well as environmental factors like travel time. The model considers the influence of urbanicity, population density, and commuting time on utilization by clustering individuals within their respective community. The average number of doctor visits for our sample is 4.8 and on average, participants travel approximately 28 minutes to utilize health services. Over 90% of participants have insurance, with approximately 6% and 10% postponing utilizing health services due to the inability to miss work or the out of pocket expense of services, respectively.  Our model had significant fixed effects for travel time, health status, insurance, and inability to miss work.  Gender and out-of-pocket expense are significant individual level predictors at an alpha level of 5% and the interaction of insurance and the RUCA code is marginally significant (p-value=0.061).  The model explains approximately 13% of total variance in healthcare utilization and 10% of variance of average healthcare utilization by census tract.