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Multiple studies have documented higher uninsurance rates among rural compared to urban residents, yet the relative adequacy of coverage among rural residents with private health insurance remains unclear. This study estimates underinsurance rates among privately insured rural residents (both adjacent and nonadjacent to urban areas) and the characteristics associated with rural underinsurance. We found that 6 percent of privately insured urban residents were underinsured; the rate increased to 10 percent for rural adjacent and 12 percent for rural nonadjacent residents. Multivariate analyses suggest that rural residents' underinsurance status is related to the design of the private plans through which they have coverage. [ABSTRACT FROM AUTHOR]

Background: Trends in the prevalence of hepatitis C virus (HCV) infection among women delivering live births may differ in rural vs. urban areas of the United States, but estimation of trends based on observed counts may lead to unstable estimates in rural counties due to small numbers., Objectives: The objective of the study was to use small area estimation methods to provide updated county-level prevalence estimates and, for the first time, trends in maternal HCV infection among live births by county-level rurality., Methods: Cross-sectional natality data from 2016 to 2020 were used to estimate maternal hepatitis C prevalence using hierarchical Bayesian models with spatiotemporal random effects to produce annual county-level estimates of maternal HCV infection and trends over time. Models included a 6-level rural-urban county classification, year, maternal characteristics and county-specific covariates. Data were analysed in 2022., Results: There were 90,764/18,905,314 live births (4.8 per 1000) with HCV infection reported on the birth certificate. Hepatitis C prevalence was higher among rural counties as compared to urban counties. Rural counties had the largest annual increases in maternal hepatitis C prevalence (per 1000 births) from 2016 to 2020 (micropolitan: 0.39; noncore: 0.40), with smaller increases among less densely populated urban counties (medium metro: 0.28; small metro: 0.28) and urban counties (large central metro:0.11; large fringe metro: 0.14)., Conclusions: The prevalence of maternal HCV infection was the highest in rural counties, and rural counties saw the greatest average prevalence increase during 2016-2020. County-level data can help in monitoring rural-urban trends in maternal HCV infection to reduce geographic disparities., (© 2022 John Wiley & Sons Ltd.)

Paid sick leave (PSL) is associated with health care access and health outcomes. The COVID-19 pandemic highlighted the importance of PSL as a public health strategy, yet PSL is not guaranteed in the United States. Rural workers may have more limited PSL, but research on rural PSL has been limited. We estimated unadjusted and adjusted PSL prevalence among rural versus urban workers and identified characteristics of rural workers with lower PSL access using the 2014-2017 Medical Expenditure Panel Survey. We found rural workers had lower access to PSL than urban workers, even after adjusting for worker and employment characteristics. Paid sick leave access was lowest among rural workers who were Hispanic, lacked employer-sponsored insurance, and reported poorer health status. Lower rural access to PSL poses a threat to the health and health care access of rural workers and has implications for the COVID-19 public health emergency and beyond.

Purpose: Electronic health records (EHRs) can facilitate primary care providers' (PCPs) use of best practices in addressing tobacco dependence. It is unknown whether rural PCPs reap the same benefits as their urban counterparts when employing EHRs for this purpose. Our study examines this issue., Methods: This cross-sectional investigation based on the 2012-2015 National Ambulatory Medical Care Survey used chi-square tests and adjusted logistic regression models to explore how rurality and use of tobacco-related EHR functions were related to smoking status documentation (SSD) and cessation treatment at adult primary care visits., Findings: SSD rates were similar in visits to rural- and urban-based PCPs (88.2% rural-based vs 81.1% urban-based, P = .5819). Use of EHRs for SSD was associated with higher SSD odds at visits to both rural- and urban-based PCPs, but this increase was greater for visits to rural-based PCPs (428% vs 220% urban-based, P = .0443). Rates of cessation treatment at smokers' visits were low in rural and urban contexts (19.3% rural vs 19.6% urban, P = .9430). Odds of cessation treatment were 68% higher where EHRs were used to remind PCPs of treatment guidelines (P = .001), with no rural-urban difference in the size of the increase. Access to EHRs with tobacco-related functions was similar across rural and urban practices., Conclusions: Rural-based PCPs were at least as successful as urban-based PCPs in leveraging EHRs to enhance tobacco-related services. Even where EHRs are used, opportunities exist to expand cessation treatment in rural primary care., (© 2021 National Rural Health Association.)

Background: Out-of-hospital births have been increasing in the United States, and home births are almost twice as common in rural vs. urban counties. Planned home births and births in rural areas have each been associated with an increased risk of infant mortality., Objectives: To estimate the effect of birth setting on infant mortality in the United States and how this is modified by rural-urban county of maternal residence., Methods: We conducted a population-based cohort study of infants born in the United States during 2010-2017 using the National Center for Health Statistics' period-linked birth-infant death files. Unadjusted and adjusted Poisson regression models were used to calculate infant mortality rate ratios and 95% confidence intervals for out-of-hospital births vs. hospital births stratified by maternal residence. Relative excess risk due to interaction (RERI) was calculated to assess effect measure modification on the additive scale., Results: The study included 25,210,263 live births. Of rural births, 97.8% was in hospitals, 0.5% was in birth centres, and 1.5% was planned home births; of urban births, 98.6% was in hospitals, 0.5% was in birth centres, and 0.7% was planned home births. After adjusting for maternal demographics and markers of high-risk pregnancy and stratifying by maternal residence, infant mortality rates were generally higher for out-of-hospital as compared to hospital births (e.g. rural planned home births aRR 1.62, 95% confidence interval [CI] 1.42, 1.85, and rural birth centre aRR 1.33, 95% CI 1.05, 1.68). There were positive additive effects of rural residence on infant mortality for planned home births and birth centre births., Conclusions: Within both rural and urban areas, out-of-hospital births generally had higher rates of infant mortality than hospital births after accounting for maternal demographics and markers of high-risk pregnancy. The risks associated with planned home births and birth centre births were more pronounced for women in rural counties., (© 2022 John Wiley & Sons Ltd.)

Introduction: The prevalence of hepatitis C virus infection among women delivering live births in the U.S. may be higher in rural areas where county-level estimates may be unreliable. The aim of this study is to model county-level maternal hepatitis C virus infection among deliveries in the U.S., Methods: In 2020, U.S. natality files (2010-2018) with county-level maternal residence information were used from states that had adopted the 2003 revised U.S. birth certificate, which included a field for hepatitis C virus infection present during pregnancy. Hierarchical Bayesian spatial models with spatiotemporal random effects were applied to produce stable annual county-level estimates of maternal hepatitis C virus infection for years when all states had adopted the revised birth certificate (2016-2018). Models included a 6-Level Urban-Rural County Classification Scheme along with the birth year and county-specific covariates to improve posterior predictions., Results: Among approximately 32 million live births, the overall prevalence of maternal hepatitis C virus infection was 3.5 per 1,000 births (increased from 2.0 in 2010 to 5.0 in 2018). During 2016-2018, posterior predicted median county-level maternal hepatitis C virus infection rates showed that nonurban counties had 3.5-3.8 times higher rates of hepatitis C virus than large central metropolitan counties. The counties in the top 10th percentile for maternal hepatitis C virus rates in 2018 were generally located in Appalachia, in Northern New England, along the northern border in the Upper Midwest, and in New Mexico., Conclusions: Further implementation of community-level interventions that are effective in reducing maternal hepatitis C virus infection and its subsequent morbidity may help to reduce geographic and rural disparities., (Copyright © 2021 American Journal of Preventive Medicine. All rights reserved.)

Purpose: Policy and reproductive health practice changes in the past decade have affected use of different contraceptive methods, but no study has assessed contraceptive method use over this time by rural-urban residence in the United States., Methods: We used female and male respondent data (2006-2017) from the National Survey of Family Growth (n = 29,133 women and n = 24,364 men) to estimate contraceptive method use by rural-urban residence over time and contraceptive method use by age, marital status, and parity/number of children., Results: From 2006-2010 to 2013-2017, among urban women, we found increased use of two or more methods (11% to 14%); increased use of intrauterine devices (5% to 11%), implants (0 to 2%), and withdrawal (5 to 8%); and decreased use of sterilization (28% to 22%) and pills (26% to 22%). Among rural women, we found increased use of intrauterine devices (5% to 9%) and implants (1% to 5%). We found increased withdrawal use for urban men, but otherwise no differences among men across time. In data pooled across all survey periods (2006-2017), contraceptive method use varied by rural-urban residence across age, marital status, and parity/number of children., Conclusions: In a nationally representative sample of reproductive age women and men, we found rural-urban differences in contraceptive method use from 2006-2010 to 2013-2017. Describing contraceptive use differences by rural-urban residence is necessary for tailoring reproductive health services to populations appropriately., (Copyright © 2020 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: To estimate differences in emergency contraception (EC) use, access, and counseling by rural-urban residence among reproductive age women in the United States., Study Design: We examined respondent data (2006-2017) from the National Survey of Family Growth for women ages 15-44 ( n = 28,448) to estimate EC use, access, and counseling by rural-urban county of residence. Rural-urban prevalence ratios for EC outcome measures were estimated using predicted margins from logistic regression models, which were adjusted for demographic differences and current contraceptive method use. Changes in ever-use of EC over time were estimated for rural and urban respondents, separately, using Chi-square tests and trends were estimated using inverse variance weighted linear regression models., Results: During 2006 to 2017, 10% of rural and 19% of urban women who had ever had sex reported ever using EC pills. Among rural women, ever-use increased from 6% in 2006-2008 to 15% in 2015-2017 (Chi-square p < 0.01; trend p -value < 0.01); among urban women, ever-use increased from 11% to 27% (Chi-square p < 0.01; trend p -value < 0.01). Rural and urban women were similarly likely to have obtained EC without a prescription and from a drug store. Rural women were less likely to have received EC counseling than urban women; however, counseling rates were low among all women., Conclusion: We observed differences in EC ever-use and receipt of EC counseling by rural-urban residence among US women ages 15 to 44, adding to the evidence that rural-urban residence is an important factor in reproductive health. More research is needed to explore factors contributing to rural-urban differences in EC use., Implications: Our key finding that EC use varied by rural-urban county residence offers additional evidence that rural-urban residence should be considered in reproductive health practice and policy. We discuss areas for future research into potential barriers to EC use in rural populations., (© 2021 The Authors.)

Background: We sought to describe lung cancer prevalence and mortality in relation to socioeconomic deprivation and rurality., Methods: We conducted a population-based cross-sectional analysis of prevalent lung cancers from a statewide all-payer claims dataset from 2012 to 2016, lung cancer deaths in Maine from the state death registry from 2012 to 2016, rurality, and area deprivation index (ADI), a geographic area-based measure of socioeconomic deprivation. Analyses examined rate ratios for lung cancer prevalence and mortality according to rurality (small and isolated rural, large rural, or urban) and ADI (quintiles, with highest reflecting the most deprivation) and after adjusting for age, sex, and area-level smoking rates as determined by the Behavioral Risk Factor Surveillance System., Results: Among 1 223 006 adults aged 20 years and older during the 5-year observation period, 8297 received lung cancer care, and 4616 died. Lung cancer prevalence and mortality were positively associated with increasing rurality, but these associations did not persist after adjusting for age, sex, and smoking rates. Lung cancer prevalence and mortality were positively associated with increasing ADI in models adjusted for age, sex, and smoking rates (prevalence rate ratio for ADI quintile 5 compared with quintile 1 = 1.41, 95% confidence interval [CI] =1.30 to 1.54) and mortality rate ratio = 1.59, 95% CI = 1.41 to 1.79)., Conclusion: Socioeconomic deprivation, but not rurality, was associated with higher lung cancer prevalence and mortality. Interventions should target populations with socioeconomic deprivation, rather than rurality per se, and aim to reduce lung cancer risk via tobacco treatment and control interventions and to improve patient access to lung cancer prevention, screening, and treatment services., (© The Author(s) 2020. Published by Oxford University Press.)

Background: Previous studies have examined timing of sexual initiation in the United States, but little is known about rural-urban differences in age at first sex., Methods: We used female respondent data from the National Survey of Family Growth (n = 29,133; 2006-2010 and 2011-2017) to examine age at first vaginal sex with a male partner. We used the Kaplan-Meier estimator and Cox proportional hazard analyses to assess differences in age at first sex by rural-urban residence, overall and stratified by 5-year birth cohorts (1968-1997). Models were adjusted for respondent characteristics and accounted for complex survey design., Results: Overall, rural women experienced first sex earlier compared with urban women (hazard ratio [HR], 1.20; 95% confidence interval [CI], 1.12-1.29). By age 18, 62% of rural women had experienced first sex, compared with 54% of urban women. After adjustment for respondent characteristics, HRs were attenuated, but rural women were still more likely to have experienced first sex compared with urban women (HR, 1.07; 95% CI, 1.01-1.13). In unadjusted models, rural women were more likely to have experienced first sex compared with urban women for most birth cohorts (HRs ranged from 1.14 to 1.32); for only one cohort (1988-1992) was this association found in the adjusted analysis (HR, 1.23; 95% CI, 1.09-1.39)., Conclusions: Women living in rural areas were generally more likely to report first sex at an earlier age compared with urban women, suggesting that delivery of sexual education and reproductive health services for women in the United States may need to take into account rural-urban residence., (Copyright © 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine change over time in cigarette smoking among rural and urban adolescents and to test whether rates of change differ by rural versus urban residence., Methods: We used the 2008 through 2010 and 2014 through 2016 US National Survey of Drug Use and Health to estimate prevalence and adjusted odds of current cigarette smoking among rural and urban adolescents aged 12 to 17 years in each period. To test for rural-urban differences in the change between periods, we included an interaction between residence and time., Results: Between 2008 to 2010 and 2014 to 2016, cigarette smoking rates declined for rural and urban adolescents; however, rural reductions lagged behind urban reductions. Controlling for socioeconomic characteristics, rural versus urban odds of cigarette smoking did not differ in 2008 through 2010; however, in 2014 through 2016, rural youths had 50% higher odds of smoking than did their urban peers., Conclusions: Differential reductions in rural youth cigarette smoking have widened the rural-urban gap in current smoking rates for adolescents. Public Health Implications. To continue gains in adolescent cigarette abstinence and reduce rural-urban disparities, prevention efforts should target rural adolescents.

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.

Purpose: Mental Health First Aid (MHFA), an early intervention training program for general audiences, has been promoted as a means for improving population-level behavioral health (BH) in rural communities by encouraging treatment-seeking. This study examined MHFA's appropriateness and impacts in rural contexts., Methods: We used a mixed-methods approach to study MHFA trainings conducted from November 2012 through September 2013 in rural communities across the country., Data Sources: (a) posttraining questionnaires completed by 44,273 MHFA participants at 2,651 rural and urban trainings in 50 US states; (b) administrative data on these trainings; and (c) interviews with 16 key informants who had taught, sponsored, or participated in rural MHFA. Measure of Rurality: Rural-Urban Commuting Area Codes., Analyses: Chi-square tests were conducted on questionnaire data. Structural, descriptive, and pattern coding techniques were used to analyze interview data., Findings: MHFA appears aligned with some key rural needs. MHFA may help to reduce unmet need for BH treatment in rural communities by raising awareness of BH issues and mitigating stigma, thereby promoting appropriate treatment-seeking. However, rural infrastructure deficits may limit some communities' ability to meet new demand generated by MHFA. MHFA may help motivate rural communities to develop initiatives for strengthening infrastructure, but additional tools and consultation may be needed., Conclusions: This study provides preliminary evidence that MHFA holds promise for improving rural BH. MHFA alone cannot compensate for weaknesses in rural BH infrastructure., (© 2016 National Rural Health Association.)

The uninsured have poorer access to care and obtain care at greater acuity than those with health insurance; however, the differential impact of being uninsured in rural versus urban areas is largely unknown. Using data from the 2002-2007 Medical Expenditure Panel Survey, we examine whether uninsured rural residents have different patterns of health care use than their urban counterparts, and the factors associated with any differences. We find that being uninsured leads to poorer access in both rural and urban areas, yet the rural uninsured are more likely to have a usual source of care and use services than their urban counterparts. Further, controlling for demographic and health characteristics, the access and use differences between the uninsured and insured in rural areas are smaller than those observed in urban areas. This suggests that rural providers may impose fewer barriers on the uninsured who seek care than providers in urban areas.

In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs. The results of studies of the costs of defensive medicine have been inconsistent. We found that estimated savings resulting from a 10 percent decline in medical malpractice premiums would be less than 1 percent of total medical care costs in every specialty. These savings are lower than most previous estimates, and they suggest that the presumed impact of tort reform on health care costs may be overstated.

Purpose: To examine rural-urban differences in the use of mental health services (mental health and substance abuse office visits, and mental health prescriptions) and in the out-of-pocket costs paid for these services., Methods: The pooled 2003 and 2004 Medical Expenditure Panel Surveys were used to assess differences in mental health service use by rural and urban residence and average per person mental health expenditures by payer and by service type., Findings: Study findings reveal a complicated pattern of greater need among rural than urban adults for mental health services, lower rural office-based mental health use and higher rural prescription use, and no rural-urban differences in total or out-of-pocket expenditures for mental health services., Conclusions: These findings raise questions about the appropriateness and quality of mental health services being delivered to rural residents. Lower mental health spending among rural residents is likely explained by lower use of psychotherapy and other office-based services, but it may also be related to these services being delivered by lower-cost providers in rural areas. Findings suggest that an approach focusing on reducing underinsurance for all health services among rural residents may help to reduce unmet mental health needs among the rural privately insured.

Context: Although research shows higher uninsured rates among rural versus urban individuals, prior studies are limited because they do not examine coverage across entire rural families., Purpose: This study uses the Medical Expenditure Panel Survey (MEPS) to compare rural and urban insurance coverage within families, to inform the design of coverage expansions that build on the current rural health insurance system., Methods: We pooled the 2001 and 2002 MEPS Household Component survey, aggregated to the family level (excluding households with all members 65 and older). We examined (1) differences in urban, rural-adjacent, and rural nonadjacent family insurance coverage, and (2) the characteristics of rural families related to their patterns of coverage., Findings: One out of 3 rural families has at least 1 uninsured member, a rate higher than for urban families-particularly in nonadjacent counties. Yet, three fourths of uninsured rural families have an insured member. For 42% of rural nonadjacent families, this is someone with public coverage (Medicaid/SCHIP or Medicare); urban families are more likely to have private health insurance or a private/public mix., Conclusions: Strategies to expand family coverage through employers may be less effective among rural nonadjacent than urban families. Instead, expansions of public coverage or tax credits enabling entire families to purchase an individual/self-employment plan would better ensure that rural nonadjacent families achieve full coverage. Subsidies or incentives would need to be generous enough to make coverage affordable for the 52% of uninsured rural nonadjacent families living below 200% of the federal poverty level.

Context: National data demonstrate that mental health (MH) visits to the emergency room (ER) comprise a small, but not inconsequential, proportion of all visits; however, we lack a rural picture of this issue., Purpose: This study investigates the use of critical access hospital (CAH) ERs by patients with MH problems to understand the role these facilities play in rural MH needs and the challenges they face., Methods: Primary data were collected through the combination of a telephone survey and ER visit logs. Our sampling frame was the universe of CAHs at the time the survey was fielded., Key Findings: About 43% of CAHs surveyed operate in communities with no MH services, while 9.4% of all logged visits were by patients identified as having some type of MH problem. The most common problems identified were affective disorders, substance abuse, anxiety, and psychotic disorders. Only 32% of CAHs have access to on-site detoxification and 2% have inpatient psychiatric services, meaning that patients in need of these services typically must leave their communities to gain treatment., Conclusions: The lack of community resources may impact CAHs' ability to assist patients with MH problems. Among those with a primary MH condition, 21% left the ER with no or unknown treatment, as did 51% of patients whose MH condition was secondary to their emergent problem. Patients in need of detoxification or inpatient psychiatric services often must travel over an hour to obtain these services, potentially creating significant issues for themselves and their families.

Information about patterns of individual health insurance coverage is limited. Knowledge gaps include the extent to which individual insurance provides transitional versus long-term coverage, and participants' insurance status before and after being covered by an individual plan. In this study we use data from the 1996-2000 Survey of Income and Program Participation (SIPP) to examine how long the individually insured maintain their coverage; sources of coverage before and after enrolling in an individual health plan; and characteristics of those who rely on individual insurance coverage. Understanding the dynamics of this market will better inform federal and state insurance reform efforts.

Despite the potential for the State Children's Health Insurance Program to improve the health care coverage of rural children, the expansion of public health insurance to children in rural areas may be hampered by a lack of understanding about the patterns of insurance coverage they experience. This study uses the Census Bureau's 1993-1996 panel of the Survey of Income and Program Participation to evaluate differences in the duration of, and in their entry into and exit from, uninsured spells. While the average duration of new spells was shorter for rural children and most regained coverage quickly, rural children were also more likely than urban children to experience protracted spells of uninsurance. Moreover, rural children were more likely than urban children to move between public and private coverage. These findings have important implications for designing insurance expansion programs and outreach strategies to effectively enroll and retain rural children.