Differences in Health and Health Care Between Rural and Urban America

Abstract

Background: Social and economic disparities in the United States have occupied significant media and political attention since the election of 2016. In particular, the country has focused on the lack of understanding of the struggles of Americans who live outside its predominantly liberal cities. In the academic literature, there remains little objective data on the differences between urban and rural Americans, and how these differences have changed over time. The rural-urban divide within health and health care is especially poorly understood. Filling in this knowledge gap would bring evidence-based data to our political discourse, and also potentially better target policy and public health interventions. This study has three aims: a) to describe the demographic and social differences of rural and urban counties; b) to understand differences in health between rural and urban counties along major causes of death; and c) to explore differences in health care access and health delivery systems between urban and rural counties. Methods: This study uses the U.S. Census classification of all 3,142 counties as either urban or rural (defined as mostly rural or all-rural). Data from several sources were gathered to compare demographic characteristics of urban and rural counties, including the racial composition and socioeconomic status. Data from the Institute of Health Metrics and Evaluation was gathered to compare the mortality rates from all-cause mortality, cardiovascular disease, neoplasms, chronic respiratory disease, substance use disorder, and self-harm/interpersonal violence over the period of 1980-2014. Regression analysis was used to assess for differences in outcomes between rural and urban counties, adjusted for observed covariates. Data from the Area Health Resource file was used to investigate measures of access including physician density, hospital bed density, and insurance access. Two-tailed t tests were used to assess the significance of differences. Results: Rural counties on average were less diverse and poorer than their urban counterparts. In unadjusted analysis of mortality data, rural counties had higher mortality rates both overall and in most disease categories; these differences generally widened over the study period. In adjusted analyses, differences in mortality between rural and urban counties were statistically significant in overall mortality and every cause of death measured except for substance use disorder/mental health. Moreover, significant differences were found between urban and rural counties across all measures of physician density (Total physicians, primary care physicians, subspecialists, and psychiatrists) with rural counties consistently having fewer providers per capita. Conclusion: This study found differences across the various dimensions of health and health care between urban and rural counties. In the case of mortality, disparities widened over time and regression analyses demonstrated continued increasing mortality over time in all causes of death. The potential causes of this apparent disparity are unclear and likely multifactorial, ranging from socioeconomic characteristics to issues of access. The data on lower physician density in rural areas provides some understanding of the lack of availability and access to the delivery system in rural areas. Further work should be conducted to better understand these differences and policy/public health interventions should be tailored to address these health disparities if further validated.