Rural Health Disparities Linked to Socioeconomic Status, Care Access

Higher rural mortality at the state level is strongly linked to socioeconomic status, patient care access, and lack of health insurance, indicating that changes in state and federal policies could alleviate rural health disparities, according to a study published in Health Affairs. 

Since the 1980s, all-cause mortality rates in rural areas of the US have exceeded those in urban areas, researchers noted. However, there are no known, definitive causes of this difference, and researchers also haven’t examined within-state differences.

Researchers from the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center (TTUHSC) set out to determine why this disparity in mortality exists, as well as why this gap varies so much between states. 

The team developed a US rural health report card that ranked states based on their grades for outcomes and access. 

"We created this data set of every rural and urban county in the US so we could see the disparities,” said Scott Phillips, editor in chief for TTUHSC's Rural Health Quarterly magazine and a co-author to the study. 

"This latest study is the next step where we try to explain why rural areas do so much worse than urban areas when it comes to health outcomes, and why the disparities are so widely spread among the states. We noticed some patterns in the early days of working on the report card that gave us a good starting place for this study."

The study focused on five explanatory variables within each county, including socioeconomic deprivation (e.g., employment, poverty status, access to housing), uninsured rates, supply of and access to primary care physicians, percentage of racial and ethnic groups, and the number of rural and urban residents.

After examining all the data, researchers found that only three variables were applicable to higher rural mortality rates: socioeconomic deprivation, percentage of uninsured, and supply of primary care physicians. These three variables accounted for 81.8 percent of the total variance of mortality. 

The remaining variables, percentage of racial and ethnic groups and the number of rural or urban residents, were not significantly associated with mortality.

"That's an impressive finding and a very large number for this kind of study. The caveat is that correlation is not necessarily causation, but it's certainly a very strong hint that this is the direction where we need to marshal our resources and pay more attention," said Phillips.

"The number of rural-urban residents within a county is just a binary measure for the model we applied to the study because it classifies each individual as either rural or urban. We used the rural-urban continuum codes put out by the USDA. It's not perfect, but it gives us a good way to break down and divide by counties, and because the health data tends to be by counties, this helps us make sure we're comparing apples to apples."

Researchers found that the race-ethnicity variable initially indicated that the percentage of African Americans is positively associated with mortality. But after adjusting for socioeconomic deprivation, uninsured rates and patient access to primary care, the percentage of African Americans was no longer significantly associated with mortality.

"We're not saying that African Americans across the country don't have higher rates of mortality because they absolutely do,” Phillips said. “What we are saying, and what we discovered with this study, is that other disparities that African Americans face, particularly socioeconomic status and access to care, account for the higher African American mortality rates across the country."

The results also showed that the rate of Hispanic Americans was negatively associated with mortality.

“There's a raging debate on why that's the case," Phillips said. "There are various explanations from immigration patterns and diet to genetics and many other factors."

The study indicates that rural residency itself doesn’t seem to negatively impact mortality, but that rural residency tends to favor lower mortality.

"We didn't expect that, but it seems to be getting a lot of attention from people so far," Phillips said. "What it indicates is that rural dwellers would have lived longer than their urban counterparts had their socioeconomic conditions and access to health care been similar. That's a pretty exciting and novel finding as far as this study goes.”

Three states proved to be exceptions to these findings: Colorado, Montana, and Wyoming. The team plans to analyze the reasons for this in future research.

“Those three contiguous states in the Mountain West have higher urban mortality than rural mortality and we want to find out why," Phillips said. "We've got a pretty good theory, but it's going take some heavy lifting to prove it."