1. Rural Health in an Era of Health Reform
February 3, 2017
Timothy D. McBride, PhD
Brown School
Washington University in St. Louis

2. So What is Rural America?
Although the word disaprities has cache here … in rural policy work the word that often comes up is differential …
Dependent variables often looked at ….

3. What is the character of an area? Which of these are rural areas?
County 1
County 2
County 3
Median family income
$74,875
$42,748
$27,553
Percent below poverty
9.1%
23.8%
30.4%
In Labor Force
66.7%
63.9%
54.1%
College degree or more
38.3%
24.8%
8.4%
Female-headed households
13.1%
20.3%
18.5%
Percent foreign born
5.8%
6.6%
0.9%
Percent non-white
26.7%
53.7%
28.2%

4. What is the character of an area?
St. Louis County
St. Louis City
Pemiscot
Median family income
$74,875
$42,748
$27,553
Percent below poverty
9.1%
23.8%
30.4%
In Labor Force
66.7%
63.9%
54.1%
College degree or more
38.3%
24.8%
8.4%
Female-headed households
13.1%
20.3%
18.5%
Percent foreign born
5.8%
6.6%
0.9%
Percent non-white
26.7%
53.7%
28.2%
Population
994,098
354,620
20,047
County
Urban
Rural

5. Triangulation… Rural, Suburban, and Urban America

6. Defining Rural in Missouri and Illinois

7. Rural Demographics, Missouri and Illinois
Growth through March 2015:
Marketplace enrollment:
Missouri: 253,432
Illinois: 349,483
U.S.: 8.84 million
Medicaid:
Missouri: 72,741 (+8.3%)
Illinois: 529,228 (+20.2%)
U.S.: 12.8 million (+22.2%)
Medicaid expansion states: +29.2%
Non-Medicaid expansion states: +9.5%
Uninsured percentages are prior to ACA implementation in Missouri and Illinois.
Social Determinants of Health for Missouri and Illinois
Average per Capita Income, 2013
Poverty Rate 2013
Percent that did not complete high school, 2013
Unemployment Rate 2013, Rural
Rural
Statewide
Urban
Missouri
$33,430
$40,663
18.00%
14.30%
17.30%
10.70%
6.70%
6.50%
Illinois
$46,980
$39,886
15.30%
14.60%
12.60%
12.70%
9.40%
9.10%
SOURCE: Rural Assistance Center, State Guides,

8. Early Impact of ACA on Coverage

11. SOURCE: Michael Karpman. 2015
SOURCE: Michael Karpman “QuickTake: Thirty-Six Percent Drop in Uninsurance Rate for Adults in Rural Areas Narrows Rural-Urban Coverage Gap,” Urban Institute, Washington DC, February 2015. 

12. Estimated Enrollment Rates in Marketplaces, by Rating Area Population Density

13. Change in Uninsured due to ACA?
Or, even though they aren’t allowed to charge higher premiums for sicker populations, they can, in subsequent years, charge more in places where their own costs turn out to be higher – for whatver reason.
Expansion states
40% drop (from 18.4% a drop of 7.4 percentage points)
Non-expansion states
29% drop (from23.4%, drop of 6.9 percentage points)
Source: ASPE, Uninsured Change Report, March 2015

14. Medicaid Enrollment Growth
Or, even though they aren’t allowed to charge higher premiums for sicker populations, they can, in subsequent years, charge more in places where their own costs turn out to be higher – for whatver reason.
Medicaid and CHIP enrollment growth (Sept Nov. 2016)
37% growth in Medicaid Expansion States
13% growth in non-expansion states
29% growth overall in all states
Source: ASPE, Uninsured Change Report, March 2015

15. Enrolled as %Uninsured>138% FPL
Enrollment in ACA Marketplaces by Metro and Nonmetro Areas (through March 2015)
All Persons
Metro Areas
Nonmetro Areas
Enrolled
Enrolled as %Uninsured>138% FPL
United States
8,838,590
27.9%
7,563,301
28.8%
1,275,289
23.5%
Missouri
253,432
59.7%
192,180
62.2%
61,252
53.1%
Illinois
349,483
35.8%
313,242
35.2%
36,241
41.7%
Kansas
96,191
48.6%
69,370
54.0%
26,821
38.6%
Arkansas
65,694
27.0%
40,939
24,755
Iowa
45,167
30.4%
27,072
32.5%
18,095
27.8%
SOURCE: RUPRI Center for Rural Health Policy Analysis (2015), data for states operating Federally-Facilitated Marketplaces (FFMs) only

17. What Challenges do Rural Areas Face, and what Difference can ACA make?

18. Life expectancy at Birth, Missouri, 2006-2010

19. Leading Causes of Rural and Urban Deaths, Missouri and Illinois
Missouri,
Illinois, 2008
Rural
Urban
Rank
Cause
Number
All causes
253,255
349,683
19,078
28,346 1
Heart disease
71,528
92,825
Heart Disease
4,724
7,036 2
Cancer
56,874
79,523
4,233
6,269 3
Chronic Lower Respiratory disease
15,914
Stroke
20,859
Chronic Lower Respiratory Disease
1,313
1,812 4
15,887
18,829
1,222
1,958 5
Unintentional Injuries
13,482
17,417
856
1,277 6
Alzheimer's disease
7,647
9,903
Alzheimer's Disease
646
898 7
Pneumonia and Influenza
6,941
Diabetes
9,525
561
707 8
6,701
8,645
Kidney Disease
506
865 9
Kidney disease
5,592
7,133
486
804 10
Suicide
3,437
5,150
Septicemia
256
398

20. Cancer Death and Hospitalization Rates, Missouri
The death rate for cancer is higher in rural areas, but the hospitalization rate is lower.
Source: Health in Rural Missouri, Biennial Report, : Missouri Department of Health and Senior Services

21. Obesity and Smoking: Areas of Concern for Rural Missouri and Illinois
“Health in Rural Missouri”, Biennial Report, , Missouri Department of Health and Senior Services
Illinois Department of Public Health, 2013 Illinois Behavioral Risk Factor Surveillance System

22. per 1,000 Residents Number of Hospital Beds by County,
Source: Missouri Department of Health and Senior Services, Bureau of Health Care Analysis and Data Dissemination, 2009 Hospital Utilization Survey

23. Primary Care Health Professional Shortage Areas in Missouri
Source: Primary Care Physicians: Rural and Urban Disparities, Missouri Hospital Association, June 2014.

24. Primary Care Physicians Per 10,000 People, March 2010
: Rural Health Plan, Missouri Department of Health and Senior Services, Office of Primary Care and Rural Health.

25. Rural Health Care Facilities in Missouri and Illinois

26. Conclusions, Implications

27. Conclusions, Implications
Enrollment data shows overall HIMs functioning as intended
8.8 million enrolled after two years in federal marketplaces (28% of potential uninsured)
Significant drops in uninsured overall (>30%), including Medicaid expansion
Enrollment rates higher in metro areas (in most places)
Nationally, marketplace enrollment rates lower in non-metro (24%) than in metro areas (29%)
In Missouri, enrollment rates lower in non-metro (53%) than in metro areas (62%)
More analysis is needed to determine what is leading to these findings
This shows potential for improvement:
How do we increase the percentage of eligible uninsured populations enrolled in non-metro areas?