US Has Worst Geographic Health Disparities in Developed World

The United States is home to the biggest geographic health disparities in the developed world, with researchers supported by the Commonwealth Fund finding significant outcomes differences falling along rural and urban lines.

The study, published in JAMA Network Open, identified Canada, Norway, and the Netherlands as top performers in geographic health equity and indicated that the US should reflect on health policies in those nations to achieve similar results at home.

Geographic health disparities refer to the differences in clinical outcomes that happen in different geographic locations within a single area, like a single given nation. Most often, geographic health disparities refer to the differences in outcomes in rural versus urban areas.

In the US, geographic health disparities are common because rural areas tend to have fewer healthcare providers. People living in rural areas are also typically older and have a higher occurrence of chronic illness.

This latest study compared the US to 10 other similarly developed nations, including Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK.

Using responses from adults participating in the 2020 Commonwealth Fund International Health Policy (IHP) Survey, the researchers were able to quantify the healthcare experiences across 10 indicators in three domains: health status and socioeconomic risk factors, affordability of care, and access to care.

Across all countries included in the assessment, the researchers identified 21 incidences of geographic health disparities. Rurality was a protective factor for 13 of those incidences, meaning living in a rural region meant you had better outcomes for 13 of those incidences. For the remaining eight, rurality was a risk factor.

This was a perplexing finding, the researchers said, given the previously documented health risk factors associated with rurality.

“One of these factors could be attributed to a plausible underdiagnoses of mental health in rural areas that might make it look like there a lower rate of mental illness in rural areas,” they posited, using the protective effect rurality had on mental illness risk in most countries.

The mean number of geographic health disparities faced by a given country was 1.9, but that varied significantly by nation. The US had the poorest performance, with the researchers observing geographic health disparities in five of the 10 indicators included in the assessment.

For instance, in the health status and socioeconomic risk factors domain, the US showed steep disparities, particularly in health status. The US had the highest or one of the highest rates of having multiple chronic conditions, having mental health conditions, and experiencing material hardship. Germany, meanwhile, had the lowest rates of chronic conditions, mental health conditions, and experiences of material hardship.

Rural residents in the US were also the most likely to say they skipped needed medical and dental care because of cost. This was least common in Norway and Sweden.

Care access problems for rural residents were the starkest in the US, Canada, and Sweden.

For the US and Canada, which are geographically large countries, this finding is somewhat unsurprising. The geographic breadth of the US and Canada may make it more likely that there will be regions with medical personnel shortages. This is visible in the low rates of people with a usual source of care and limited ability to get a same-day appointment or access an after-hours appointment.

The Netherlands was a top performer in care access.

While the US had the steepest rural-urban health disparities, the researchers found that Canada, Norway, and the Netherlands were stand-outs, with the team noting fewer disparities in those countries.

However, the researchers did point out that previous studies have found rural-urban disparities in Canada and Norway, despite them showing no disparities in this particular analysis. Further study should look more deeply at these countries to assess the state of rural-urban health disparities, the team suggested.

Still, identifying those three countries as exemplars in geographic health equity could provide a productive roadmap for equity in the US. The researchers concluded by suggesting that US health policymakers assess the models used in Canada, Norway, and the Netherlands that contribute to better outcomes in rural and urban settings.