Urban-rural differences in employer-based health insurance coverage of workers

Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum

OBJECTIVE

To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents.

METHODS

We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison.

RESULTS

Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth.

CONCLUSION

Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Employment-Based Health Insurance: Analysis of Rural-Urban Differences in One State

This study estimates the propensity of firms to offer health insurance in a simultaneous equation model to control for the endogeneity between wages and health insurance. Previous research finds differences in rural and urban employer behavior with respect to health insurance benefits fully explained by differences in wages and firm size. In contrast, this study finds residual unexplained differences in the propensity to offer coverage that may be attributable to differences in plan supply, plan distribution, or differences in availability of substitutes for coverage (safety net care). Rural worker participation in offered coverage is more responsive to wage level than is the participation decision of urban workers. Together, these results imply that some of the differences in health insurance coverage rates for rural workers could be amenable to policy interventions.

Rural/urban differences in self-rated health: examining the roles of county size and metropolitan adjacency

This research explored the roles of 'rurality' - nonmetropolitan county population size and adjacency to metropolitan areas - on self-rated health among a nationally representative sample of US adults. Using seven years of pooled individual level data from the Behavioral Risk Factor Surveillance System and county-level data from the County Characteristics survey, we found that residents of remote rural counties have the greatest odds of reporting bad health and that the significant differences in self-rated health between metropolitan residents and residents of rural areas can be entirely explained by rural structural disadvantage, including higher rates of unemployment and population loss and lower levels of educational attainment.

The relative importance of worker, firm, and market characteristics for racial/ethnic disparities in employer-sponsored health Insurance

The characteristics of an individual, the local labor market, and the firm where an individual is employed each may be associated with racial and ethnic disparities in employer-sponsored insurance (ESI). This study estimates two models to determine the relative effects of each of these three sets of characteristics on the likelihood a worker has a job with ESI. One model has two outcomes: the job comes with ESI or not. The other model has five possible outcomes: the individual is not offered ESI and is uninsured, the individual is not offered ESI and is insured; the individual is offered ESI but turns it down and is uninsured; the individual is offered ESI but turns it down and is insured; and the individual is offered ESI and accepts. Findings indicate that individual characteristics and firm characteristics are more likely to have significant and substantial effects on the probability that a person has ESI, while the effects of market characteristics appear to be conveyed through firm characteristics. Being African American or Hispanic is not significantly associated with having ESI in the two-outcomes model, but in the five-outcomes model each is associated significantly with being uninsured, either because the person has not been offered ESI or has declined offered coverage. Clearly, examining more nuanced outcomes is more informative about the role of race and ethnicity in why working people are uninsured.

Frailty and survival of rural and urban seniors: results from the Canadian Study of Health and Aging

BACKGROUND AND AIMS

Relatively little is known about how region of residence influences frailty of seniors. Frailty indexes can be used to investigate these effects. We constructed and validated a frailty index, to investigate the differences in health status between rural and urban seniors.

METHODS

We studied rural (n=949) and urban (n=7598) older adults in the Canadian Study of Health and Aging, of whom 22% died over 72 months. The frailty index was generated from 40 self-reported health deficits (symptoms, diseases, disabilities, unfavourable living conditions).

RESULTS

The average value of the frailty index increased exponentially with age in both groups (rural: r=0.94; urban: r=0.97, p<0.01) and was highly correlated with mortality (r=0.96 for rural, r=0.97 for urban, p<0.01). Up to age 80, there were few rural-urban differences in frailty. After age 80, the rural sample showed higher mortality than the urban sample. The hazard ratio for death for each increment in the frailty index was 1.38 (1.14-1.72) in rural participants vs 1.18 (1.11-1.26) in urban participants. Women lived longer than men at any index value.

CONCLUSIONS

Frailty index analysis readily summarizes health and mortality differences between very old rural and urban dwellers, which reflect differences in deficit accumulation, and in the impact of gender on survival. The frailty index provides efficient dimensionality reduction for studying group differences in the health of older adults.

Rural-Urban Differences in Employment-Related Health Insurance

CONTEXT

Rural residents are disproportionately represented among the uninsured in the United States.

PURPOSE

We compared nonelderly adult residents in 3 types of nonmetropolitan areas with metropolitan workers to evaluate which characteristics contribute to lack of employment-related insurance. RESEARCH DESIGN AND ANALYSIS: Data were obtained from the Medical Expenditure Panel Survey, pooled across 3 panels (1996--1998) to enhance the rural sample size. Econometric decomposition was used to quantify the contribution of employment structure to differences in the probability of being offered employment-related health insurance.

FINDINGS

The most rural workers are 10.4 percentage points less likely to be offered insurance compared with urban workers; the difference is smaller for residents of other rural areas. In rural counties not adjacent to urban areas, lower wages and smaller employers each account for about one-third of the total difference.

CONCLUSIONS

Health insurance disparities associated with rural residence are related to the structure of employment. Major factors include smaller employers, lower wages, greater prevalence of self-employment, and sociodemographic characteristics.

Use, quality, and outcomes of care for mental health: the rural perspective

This review synthesizes empirical research in rural mental health services to identify current research priorities to improve the mental health of rural Americans. Using a conceptual framework of the multiple determinants of use, quality, and outcomes, the authors address (1) how key constructs are operationalized, (2) their theoretical influence on the care process, (3) reported differences for nonmetropolitan and metropolitan individuals or within nonmetropolitan individuals, (4) salient issues rural advocates have raised, and (5) key research questions. While the authors recognize that rurality is a useful political umbrella to organize advocacy efforts, they propose that investigators no longer employ any of the multiple definitions of the term in the literature as even intrarural comparisons have not provided compelling evidence about the underlying causes of observed outcomes differences. Until these underlying causes have been identified, it is difficult to determine which components of the nonmetropolitan service system need to be improved.

Patterns of health insurance coverage among rural and urban children

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.

Medicaid and rural health care

The impact of Medicaid policies on systems of rural health care has typically been understood in terms of payment methods and rates. But Medicaid agencies have multifaceted influences, including service funding, promotion of access and quality, and infrastructure. We present in this article a general framework to explore these facets and examine literature that has attempted to identify and measure the impacts of the Medicaid program on rural health care systems. While the literature is relatively sparse, there is evidence that rural health systems have been both bolstered and challenged by Medicaid policies in several areas. Several contemporary developments in Medicaid, including increased state flexibility, uneven coverage expansion, and aggressive Medicaid purchasing strategies, suggest that tensions between Medicaid policy and rural health care needs could grow in the future. These tensions provide focus for developing a research agenda that explores the intersection of Medicaid and rural concerns; a number of research questions that would be a part of this agenda are presented.

Medicaid and crowding out of private insurance: a re-examination using firm level data

While previous research has identified a relationship between expanded Medicaid eligibility and falling private health insurance coverage, the exact mechanism by which this "crowding out" occurs is largely unexplained. We combine individual and firm-level data to investigate possible responses to the Medicaid expansions by firms and workers. We find no evidence that the expansions affected employer offers of insurance to workers. However, we find some evidence of an effect on the probability that a firm offers family coverage, and on the percentage of full-time workers accepting employer-sponsored coverage offered to them.