Project Highlights

The Northern Border Region: A Health Focused Landscape

The Northern Border Regional Commission State and Region Chartbooks compile county- and state-level data related to health and health care access for the Northern Border Region and the individual states of Maine, New Hampshire, New York, and Vermont. Topics covered in the chartbooks include demographic and socioeconomic characteristics, access to care, health outcomes, mortality rates, Health Professional Shortage Areas, and the location of Rural Health Clinics, Federally Qualified Health Centers, hospitals, and substance use treatment facilities.

FMI: Katherine Ahrens, PhD (
WebinarDr. Ahrens described this project which compiled the most recent publicly available data related to health and healthcare access at the county-level and state-level for the Northern Border Region: ME, NH, NY, and VT.  Additionally, she discussed healthcare professional shortage areas and highlighted counties with worse health outcomes, as compared to the rest of the counties in the region.


Ambulance Deserts: Addressing Geographic Disparities in the Provision of Ambulance Services

The declining numbers of rural hospitals and ambulance services imply that remaining ambulance services are being tasked to play a greater role in delivering emergency services in expanded service areas. Additionally, the delivery of ambulance services has not been systematically integrated, particularly in rural areas, leading to gaps in the provision of ambulance services, also known as “ambulance deserts.” To assist state and regional policymakers in formulating strategic plans to address these gaps, this project, led by Dr. Yvonne Jonk, aims to identify geographic disparities in accessing ambulance services by identifying and mapping ambulance deserts within each state, focusing on the following research questions:

  • What areas of the states are ambulance deserts and how prevalent are they?
  • What percentage of each state’s population lives in an ambulance desert? Are there rural-urban or regional differences in the share of residents living in these deserts?

FMI: Yvonne Jonk, PhD (

Chartbook released May 2023: Ambulance Deserts: Geographic Disparities in the Provision of Ambulance Services 






Excess Deaths Associated with COVID-19 in Rural Communities

Quantifying excess deaths associated with the COVID-19 pandemic can provide a more complete measure of the total burden of the pandemic on mortality. While the National Center for Health Statistics maintains an online dashboard of US excess deaths associated with the COVID-19 pandemic overall and by race/ethnicity and age, excess deaths by rurality of residence are not tabulated and we aim to fill that gap. This project is completed and a journal article has been published in the Journal of Rural Health (early release Dec. 11, 2023). Ahrens KA, Rossen LM, Milkowski C, Gelsinger C, Ziller E. Excess deaths associated with COVID-19 by rurality and demographic factors in the United States. J Rural Health. Published online December 11, 2023. doi:10.1111/jrh.12815

FMI:  Kate Ahrens, PhD,

Health Care Use and Access Among Rural & Urban Elderly Medicare Beneficiaries

Elderly individuals age 65 and over constitute the majority of the Medicare population, and among Medicare beneficiaries, health care access problems are greater among individuals with low incomes, in poor health, and with four or more chronic conditions. These and other barriers may lead to rural-urban differences in health care use among the elderly. This study uses the 2011-2013 Medicare Current Beneficiary Survey to compare health access and use of health services among fee-for-service Medicare beneficiaries age 65 and over in rural versus urban settings, and the factors associated with rural access problems. Findings from this study will help policymakers understand the needs of the growing elderly population and how best to adjust Medicare benefit design and service delivery to reduce barriers to care.  

FMI: Yvonne Jonk, PhD

Health Care Use and Expenditures among Rural and Urban Medicare Beneficiaries Aged 85 and Over

The proportion of U.S. residents aged 85+ is expected to grow substantially in the coming decades with the impact of this growth in rural areas likely to be particularly pronounced. In light of this population’s significant health and other vulnerabilities and high costs, this project will use data from the Medicare Current Beneficiary Survey (MCBS) to examine rural-urban differences in health care use and expenditures among Medicare enrollees aged 85 and over.

FMI:  Yvonne Jonk, PhD

How are Rural Health Clinics Serving Pediatric and Obstetrical Medicaid Populations?

This mixed methods study will examine the extent to which independent and provider-based services are serving pediatric and obstetrical patients covered by state Medicaid Programs. Using Medicaid Claims and brief qualitative interviews with 9 to 12 RHCs that specifically provide pediatric or obstetrical patient services, we will address the following research questions:

  1. To what extent are RHCs providing pediatric and obstetrical services to patients enrolled in state Medicaid programs? Are there variations across states?

  2. What diagnoses are most common for Medicaid pediatric and obstetrical patients using RHCs?

  3. Are there differences in the extent to which provider-based and independent RHCs serve Medicaid pediatric and obstetrical services? Are there differences across the rural continuum and/or census regions? Are there differences in the extent to which RHCs serve pediatric and obstetrical services in Medicaid expansion vs. non-expansion states?

  4. What are the Medicaid rates and reimbursement and coverage policies for pediatric and obstetrical services provided by RHCs?

  5. What are the challenges and operational considerations encountered by RHCs providing pediatric and obstetrical services?

FMI: John Gale

Out-of-Pocket Spending Among Privately Insured Rural and Urban Residents

Out-of-pocket spending for health care services has been on the rise as deductibles and other cost-sharing requirements among the privately insured increase.  This quantitative, nationally representative study will use the Medical Expenditure Panel Survey (MEPS) to examine health plan characteristics and out-of-pocket health care spending by non-elderly, community dwelling, rural and urban residents. Using bivariate and multivariable analyses, we propose to examine the:

  • characteristics of private health insurance plans held by rural versus urban residents
  • out-of-pocket costs, total premium and spending for privately insured rural versus urban residents
  • percentage of health care spending paid out-of-pocket by rural versus urban residents and whether there are differences in out-of-pocket spending for individuals with chronic or acute health conditions, by events or socioeconomic characteristics?
  • differences in out-of-pocket spending by plan characteristics
  • percentage of rural versus urban household income represented by out-of-pocket health care spending, and whether this varies by socioeconomic and health plan characteristics

FMI: Erika Ziller, PhD

Prevalence of Opioid Prescribing, Diagnoses of Opioid Use Disorder, Treatment Patterns, and Costs Among Rural Medicare Beneficiaries

The elderly are at serious risk for opioid dependence or other harms due to higher prescribing patterns. However, there is a lack of literature on the rural-urban difference in the use and misuse of prescription opioids. Understanding these differences will help rural areas better target prevention and treatment options. We will address opioid prescribing rates among Medicare beneficiaries, using the Medicare Current Beneficiary Survey and describe differences in socioeconomic, health, and functional status of beneficiaries using prescription opioids and the general population using bivariate and logistic regression analyses. The impact of opioid use and medication-assisted therapy on health services utilization and costs will be assessed using difference in differences models.

FMI:  Yvonne Jonk, PhD

Psychiatric Bed Closures in Rural Hospitals: An Assessment of Trends, Impact, and Policy Strategies

The closure of psychiatric beds in rural hospitals increases the wait time for mental health care and forces correctional facilities as well as hospital emergency departments, skilled nursing facilities, nursing facilities, and other health care providers to bear the burden of housing these patients until services become available. This study will examine trends in the closure of psychiatric beds by rural hospitals using the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Services Locator, the American Hospital Association (AHA) Annual Survey of Hospitals (2010-2017), and the Area Health Resources File.

FMI: John Gale, MS

Public Health Insurance Coverage among Rural and Urban Children

In recent decades, Medicaid and the Children’s Health Insurance Program (CHIP) have represented important sources of health insurance coverage for children, particularly those who live in rural areas. However, data suggest that the number of U.S. children covered by these public insurance sources has declined in recent years. Between 2016 and 2019, rates of public coverage among children declined slightly (39.5% to 37.1%) while the number of uninsured children increased by nearly 700 thousand. Some have speculated that changes in state health policy, particularly Medicaid eligibility shifts, have played a role in this coverage decline. However, it is unclear whether rural versus urban children have experienced comparable rates of decline or whether there have been geographic differences (by rurality or region) or disparities among specific rural populations. This study will address that gap using the Census Bureau’s American Communities Survey (ACS). Specifically, we will examine what percentage of rural and urban children was covered by Medicaid/CHIP in 2016-2020 versus 2011-2015 and whether any observed changes differ by rural-urban residence. We will also estimate who are the children eligible but unenrolled in Medicaid/CHIP and whether there are there rural-urban differences.

FMI: Erika Ziller, PhD,

Rural Health Access: Affordability and Barriers to Care

While the Affordable Care Act (ACA) led to pronounced gains in insurance coverage in rural areas, particularly among low-income individuals, rural residents continue to have higher rates of uninsurance than their urban counterparts. Research also suggests that paying for health care remains a substantial rural concern: A recent survey of rural adults identified financial challenges, followed by health and health care issues, as the most pressing problems facing rural families, with many citing affordability as the reason for delaying or foregoing needed care. Although we know that health care affordability remains a concern for many rural residents, it is unclear to what extent factors such as insurance coverage gains or the growing trend of high deductible health plans (HDHPs) have influenced rural experiences of cost-related barriers to care, and whether rural populations continue to experience more such barriers than do urban residents. This quantitative, nationally representative study will address this research gap by comparing rural and urban differences in health care access and affordability.

FMI: Erika Ziller, PhD,

Rural Poverty and Health: A Chartbook

Using the Medical Expenditure Panel Survey (MEPS), The National Health Interview Survey (NHIS), and the National Survey of Drug Use and Health (NSDUH), we will examine relationships between poverty and health for community-dwelling rural and urban residents of all ages.  Analysis of county-level health-related measures using the County Health Rankings will supplement the national survey data. We will produce a chartbook that addresses the following research questions:

  1. Among rural residents, do individuals who are poor, or near-poor differ from their non-poor counterparts with respect to health status, health care access and use, risk/protective factors, and physical environment?
  2. Among individuals who are poor or near-poor, are there rural-urban differences on the health-related measures of interest (mentioned above)?
  3. Are rural-urban differences on health-related measures greater among individuals who are poor or near-poor than among those who are non-poor?
  4. What additional factors are associated with rural poverty and health, and do relationships between these factors and poverty differ across rural and urban contexts?
  5. What are the health-related characteristics of rural counties with high rates of poverty and persistent poverty? How do these counties compare to non-poor rural counties and poor urban counties on health-related metrics?

FMI: Jean Talbot, PhD

Rural-Urban Differences in Out-of-Pocket Prescription Drug Spending

This study will use the Medical Expenditure Panel Survey to examine out-of-pocket spending on prescription medication from 2014-2017. Specifically, we propose to analyze total spending and out-of-pocket spending for rural versus urban residents. We will identify the percentage of prescription drug spending that is paid out-of-pocket by rural and urban residents—across all drugs and within certain drug classes of interest (e.g., medications for diabetes, behavioral health conditions, asthma, and cancer). We will also examine how rural and urban out-of-pocket spending for prescription drugs differ based on health insurance coverage and other socioeconomic variables.

FMI: Erika Ziller, PhD

Socioeconomic Profiles and Market Characteristics Associated with Ambulance Deserts

This project builds on our recent work identifying areas across the country lacking adequate access to ambulance services (i.e., ambulance deserts). Because these areas are newly identified, little is known of the populations living in ambulance deserts or of the market characteristics associated with ambulance deserts. Factors contributing to ambulance deserts include:

  • Declining number of rural hospitals and ambulance services
  • Lack of integration of ambulance services into the rural healthcare system
  • Gaps in the provision of rural ambulance services, increasing the geographic coverage areas for existing ambulance services.

To assist state and regional policymakers in formulating strategic plans to address these gaps we will use our existing ambulance and ambulance desert location data and data from the U.S. Census to identify vulnerable populations living within ambulance deserts and the implications associated with traveling to the nearest health care facility capable of serving the emergent healthcare needs of these vulnerable populations.

FMI: Yvonne Jonk, PhD,

Understanding Rural Health Clinic Services, Use, and Reimbursement

This study will use Medicare claims data to describe the scope and intensity of services provided to Medicare beneficiaries by independent and provider-based Rural Health Clinics (RHC)s. This study will address the following research questions:

  • What are the most common diagnoses for Medicare beneficiaries using RHCs?
  • What are the characteristics and intensity of the services (e.g. E&M services, other procedures) provided by RHCs?
  • Are there differences in the intensity and type of clinical services provided by different types of RHCs (i.e. provider-based vs. independent) and across the rural continuum and/or census divisions/regions?
  • What types of non-RHC services are RHCs billing to Medicare Part B (e.g. care management, telehealth, inpatient E&M services, other procedures)?
  • How do estimated fee for service payments to RHCs under CMS’s changes to the outpatient E&M codes in 2021 compare to the 2021 per-visit reimbursement cap?

FMI: John Gale, MS

Understanding Rural Non-Emergent Emergency Department Use

Research indicates that rural residents use the emergency department (ED) at higher rates than their urban counterparts, with recent analyses indicating that this rural-urban difference has been increasing. Additional studies suggest that rural residents are more likely to visit the ED for a non-emergent reasons. However, the reasons for these higher rates remain unclear. This difference could be the result of rural primary care access barriers, including availability of after-hours care, or could be related to lower education or other factors affecting knowledge of appropriate healthcare use. This study will use the 2014-2017 Medical Expenditure Panel Survey to analyze the factors associated with rural versus urban residents’ non-emergent ED use.

FMI: Erika Ziller, PhD

Unmet Health and Social Needs of Rural Residents with Disability

There is growing evidence that a consequential percentage of individuals who become infected with COVID-19 will develop long-term health conditions, some of which may be disabling. Even before the public health emergency, disability was a substantial concern in the United States, affecting more than 61 million adults nationally. Prior research has confirmed that the prevalence of disability is particularly pronounced in rural communities and rural residents experience disability at higher rates than their urban counterparts. Some analyses have suggested that rural-urban disparities in disability prevalence are particularly pronounced among Black and other minoritized races and ethnicities. Extensive research suggests individuals with physical and mental disabilities may experience multiple barriers to needed healthcare and social supports. Although research is limited, poorer access to insurance coverage, lower rates of specialty care availability, and greater travel distances may place rural residents at greater risk for unmet needs, and some single-state and qualitative studies suggest that rural residents with disabilities struggle to obtain primary and specialty care because of affordability, availability, and transportation issues. However, the lack of national data on rural-urban differences in access to healthcare services may limit policymakers’ abilities to develop comprehensive strategies to address any access concerns. This project will address this gap by examining rural-urban differences in access to health care and social wellbeing for adults experiencing disability.

FMI: Erika Ziller, PhD,

Use of Z codes by Rural and Urban Providers to Capture Data on the Social Determinants of Health Impacting Medicare Beneficiaries

There is wide recognition that social determinants of health (SDOH) are significant drivers of health risks and outcomes and account for more than 60 percent of an individual’s overall health.  Recent research has recognized the importance of SDOH data and the necessity of collecting these data to empower providers to address health disparities. Despite this, the collection of SDOH data remains inconsistent. Z codes are a set of reason codes within the ICD-10-CM introduced in 2015 to capture data on SDOH impacting the health of patients. Previous studies have documented higher rates of the top five chronic conditions (hypertension, depression, hyperlipidemia, rheumatoid arthritis, and chronic kidney disease) among Medicare fee-for-service (FFS) beneficiaries with reported Z codes compared to all Medicare FFS beneficiaries. Research has found use of Z codes to be low.

We will examine 2019-2021 Medicare inpatient, outpatient, and carrier claims data to evaluate the use of Z codes by rural and urban providers to capture information on SDOHs affecting the health of rural Medicare FFS beneficiaries by age, gender, and rural residence across the rural continuum. We will interview key provider types from critical access hospitals and other rural and urban hospitals, rural health clinics, and federally qualified health clinics to understand opportunities to improve the use of Z codes by these providers.

FMI: John Gale, MS, and Kate Ahren, PhD,



A Current Examination of HIV and Hepatitis C in Rural Counties

Rural counties have witnessed significant growth in opioid pain reliever misuse and initiation of injection drug use. As a result, human immunodeficiency virus (HIV) prevalence, acute hepatitis C virus (HCV) incidence, and maternal HCV infection have grown among certain rural subpopulations over the past decade. Establishing current, county-level HIV prevalence and acute HCV incidence estimates across the rural-urban continuum could inform policies and practices aimed at addressing the transmission and treatment of HIV and HCV in rural areas. Using existing data from federal and state sources, we produced a chartbook on county-level data on HIV prevalence and acute HCV incidence, and examined the availability of Ryan White HIV/AIDS medical providers and other HIV and HCV treatment and testing services across the rural-urban continuum. Our findings showed that HIV prevalence for rural counties was highest in southern states; but within these states, rates were higher in urban counties than rural. We also found lower availability of Ryan White providers in rural compared with urban counties. Using data from the U.S. natality files, our associated peer-reviewed article examines rural-urban differences in county-level rates of maternal infection with hepatitis C virus (HCV) during 2010-2018. Findings can help inform implementation of community-level interventions to reduce maternal HCV infection and narrow rural-urban disparities.              Completed publications:

FMI: Katherine Ahrens, PhD or Amanda Burgess, MPPM, MPH

Access to Mental Health Services and Family Burden of Rural Children with Significant Mental Health Problems
The needs of rural children with SED and the burden these needs place on their families are intertwined and may place these rural children and their families at “double jeopardy” of having their mental health and other needs go unmet. Using the National Survey of Children with Special Health Care Needs (NS-CSHCN) and information on community characteristics from the Area Resource File (ARF) we examined the factors associated with whether children and their families have their needs meet across the rural continuum. View or download the Research & Policy Brief or the full report.
Access to and Use of Home and Community-Based Services in Rural Areas.
This study used data from the 2010 Medicaid Analytic eXtract (MAX) file, in-depth policy reviews to examine differences in the use of institutional and home and community-based service (HCBS) use by older adults across urban and rural areas, and the policy and community factors that contribute to differences or comparability in use. View or download the Research & Policy Brief.
Acuity Differences Among Newly Admitted Rural and Urban Nursing Home Residents

Building on studies showing differences in how rural and urban older adults access and use long-term services and supports (LTSS), this study will use national, standardized Medicare and non-Medicare nursing home assessment data (MDS 3.0) to to assess rural-urban acuity differences among newly-admitted older nursing home residents. Study findings will inform federal and state policy strategies to enable rural (and urban) older adults to access LTSS services most appropriate to their social, health, and functional needs. This study is complete and findings were published in The Gerontologist (doi:10.1093/geront/gnaa183).

FMI: Yvonne Jonk, PhD,

Adolescent Alcohol Use in Rural Areas: What are the Issues?
Previous research has shown that rural adolescents are more likely to use alcohol than those in urban areas adolescents and that the more rural the area, the higher the use. Moreover, current knowledge suggests that risk and protective factors may operate differently for rural adolescents. This study used five years of NSDUH pooled data to examine the underlying factors that account for urban-rural and intra-rural differences in adolescent alcohol use and how this knowledge may be used to develop targeted alcohol prevention and intervention programs for rural youth. View or download the Research & Policy Brief or the full report.
Adverse Childhood Experiences (ACEs) and the Health Status of Rural Residents.
Although adverse childhood experiences (ACEs) have been identified as important risk factors for the development of chronic illness and harmful health behaviors, researchers have not yet systematically examined ACEs and their linkages with health outcomes in the rural context. Using data from the data from the Behavioral Risk Factors Surveillance Survey, research staff assessed the prevalence of adverse childhood experiences (ACEs) in rural populations and examined associations of ACEs with health outcomes in rural versus urban settings. View or download the Research & Policy Brief.
Ambulance Deserts: Addressing Geographic Disparities in the Provision of Ambulance Services

Declining numbers of rural hospitals and ambulance services imply that remaining ambulance services are being tasked to play a greater role in delivering more sophisticated emergency services in expanded service areas, yet EMS has not been systematically integrated within the healthcare delivery system. Research has shown that this lack of systems planning has led to gaps in the provision of ambulance services, exacerbated across larger geographic coverage areas. These gaps—referred to as “ambulance deserts”—are steadily increasing. To assist state and regional policymakers in formulating strategic plans to address these gaps, this 2-year project will employ a systematic methodology within a geographic information system (GIS) framework for identifying the adequacy of the existing sets of ambulance services (by state) to meet the needs of the communities they serve, and the extent to which states have populated areas that are not served by any ambulances. Year one activities will focus on building a database of ambulance service locations, which will be followed up in year two with  identifying and creating maps of ambulance deserts within each of the selected study states. A chartbook was released in May 2023.

FMI:  Yvonne Jonk, PhD,

Assessing Health Information Technology (HIT) Strategies to Improve Access for Rural Veterans
Rural veterans face unique barriers to care including insufficient communication and coordination of care provided across multiple settings—both within and outside of the Veteran’s Administration. To help reduce these barriers, multiple agencies within the federal government have promoted technology as an opportunity to improve access and care coordination to veterans living in remote areas. Most recently, programs in Maine, Montana and Alaska have received grants to use health information technology (HIT) to expand and integrate services—including mental health services—for rural Veterans. However, little is known about the challenges these programs face on the ground, or what conditions and program strategies may facilitate success. This case study of Maine’s program identifies best practices and barriers for implementing rural HIT initiatives that could inform future strategies in this population. View or download the report.
Assessing HIT Readiness of Rural Health Clinics: A National Survey.
Research staff designed and conducted a national survey of rural health clinics, both independent and provider-based, to determine the current level of health information technology adoption and readiness in these clinics. View or download the Research & Policy Brief or the full report.
Capacity of Rural Counties to Respond to an HIV or Hepatitis C Outbreak

Rural counties may be potentially vulnerable to an HIV or hepatitis C outbreak among persons who inject drugs. Using mixed methods, we provide an understanding of the rural areas at risk of an outbreak based on their state and county characteristics and an assessment of their public health infrastructure.  Completed publications:

FMI: Amanda Burgess, MPPM, MPH (

Catastrophic Consequences: The Rise of Opioid Abuse in Rural Communities.
Heroin use has grown significantly in recent years, particularly among those reporting nonmedical use of opioid pain relievers before initiating heroin. Past research has indicated that opioid pain reliever use is higher among specific rural populations than urban, including adolescents and young adults. This study examined the rural-urban prevalence of non-medical use of pain relievers and heroin in the past year and the socio-economic characteristics associated with their use as well as treatment history and perceived need for treatment; perceived risk of using drugs; and other risky behavior, using data from the National Survey of Drug Use and Health (NSDUH). Key informant interviews with officials in four were conducted to understand the challenges and promising practices in monitoring opiate prescribing and diversion, prevention interventions, and opioid prevention and treatment infrastructure in rural communities.The project is complete, with a Research & Policy Brief focusing on prevalance statistics and a Working Paper and associated Research & Policy Brief highlighting  treatment strategies in four states. This project also resulted in a book chapter: Lenardson JD, Smith ML. Catastrophic consequences: The link between rural opioid use and HIV/AIDS. In: Parks FM, Felzien GS, Jue S, eds. HIV/AIDS in Rural Communities: Research, Education, and Advocacy. New York, NY: Springer International Publishing; 2017:89-108. doi: 10.1007/978-3-319-56239-1_7.
Challenges and Opportunities for Improving Rural Long-Term Services and Supports: Integrated Care Management in Rural Communities
This study reviews the opportunities and challenges reform initiatives under the Affordable Care Act present for rural communities. The study assesses four types of organizational models for delivering integrated care management. Each model has different strengths and drawbacks, weighing for and against implementation in rural areas. View or download the Research & Policy Brief or the report here.
Challenges and Opportunities for Improving Rural Long-Term Services and Supports under the Affordable Care Act
This project examined strategies, models, and policy options for improving access to, and quality of, rural long-term services and supports. View or download the Research & Policy Brief here.
Consequences of Rural Uninsurance
This study assessed whether uninsured rural residents have different levels of access to care than their urban counterparts, and the factors associated with any differences (including sub-analyses for individuals with identified chronic conditions). In doing so, it will provide policymakers with critical information for improving rural health systems. View or download the Research & Policy Brief.  This study also resulted in a peer-reviewed article: Ziller, E.C., Lenardson, J.D., & Coburn, A.F. (2012). Health care access and use among the rural uninsured. Journal of Health Care for the Poor and Underserved, 23(3), 1327-1345.
Developing a Sentinel Cohort of Rural Health Clinics for Use in Developing Relevant Quality Measures and Monitoring Program Performance.
This two year project assembled a cohort of Rural Health Clinics (RHCs) across thirteen states to participate in a sentinel quality measurement process. During the first year of the project, the project team worked with the cohort of RHCs along with an expert panel of RHC and quality measurement experts to identify, develop, and refine of a discrete set RHC quality measures. During the second year, the cohort implemented the reporting process, collected data from the RHCs on the quality measures, and evaluated the measures in terms of performance and quality improvement. View or download the Research & Policy Brief on the pilot testing of the RHC quality measurement reporting system..
Eligibility Transitions under the Affordable Care Act: Policy Considerations for Ensuring Coverage Continuity Among Rural Residents.
This study will assess rural versus urban income volatility, the potential effects on states’ efforts to ensure continuous health insurance coverage to individuals enrolled in Medicaid expansions or Exchange plans under the Affordable Care Act, and develop policy recommendations to address any observed differences. View or download the Research and Policy Brief.
Expanded Look at Rural Access to Care.
Recently, the access modules of the National Health Interview Survey (NHIS) have been modified to delve more deeply into individuals’ experiences of barriers to care. These new questions on access, use, and affordability, implemented in response to the Affordable Care Act (ACA), represent an important opportunity to better understand rural-urban differences in access to care and to monitor ACA implementation from a rural perspective. Using the 2011-2012 NHIS, this study provides detailed information about rural-urban differences among adults under age 65 in perceived affordability of health insurance coverage and services prior to implementation of the Affordable Care Act. View  or download the Research & Policy Brief.
Health Care Access and Affordability Among Rural Children with Public Versus Private Health Insurance.
To examine differences in health care access and affordability among rural children with public (i.e., Medicaid or CHIP) and private health insurance coverage, the study addressed the following research questions, using data from the 2011-12 National Survey of Children’s Health: Do low-income rural families report differences in access to health care services for their publicly versus privately insured children? What are the differences in families’ perceived affordability of premiums and cost sharing for low-income children with public versus private health insurance coverage? How do these patterns of access to care and affordability vary between rural and urban children with public and private coverage? View or download the Research & Policy Brief.
Health Insurance Stability among Rural Children Following Public Coverage Expansions
While estimates indicate that the uninsured rate among rural children has dramatically decreased since the 1997 passage of the State Children’s Health Insurance Program (CHIP), it is not clear whether or not coverage has become more stable and uninsured spells shorter. The purpose of this study was to investigate changes in insurance stability among rural and urban children following CHIP, and whether this was affected by specific state eligibility and enrollment policies or clusters of policies. This study found that following the CHIP’s implementation, health insurance coverage and continuity increased among low-income children, particularly for those living in rural areas. By CHIP’s maturity, coverage for rural children improved so much that their uninsured rate dropped below that of urban children. View or download the Research & Policy Brief.
Health Care Use and Access Among Rural & Urban Non-elderly Disabled Medicare Beneficiaries
This project explores health care use and barriers to health care access among disabled Medicare beneficiaries under 65 in rural and urban areas. The study is based on quantitative analyses of the 2009-2013 Medicare Current Beneficiary Survey, finding that the characteristics of nonelderly Medicare beneficiaries with a disability reflected the differences observed between rural and urban populations overall, with certain rural subgroups reporting greater challenges accessing care. Download or view the Research and Policy Brief.
FMI: Erika Ziller, PhD
Impact of Employment Transitions on Health Insurance Coverage of Rural Residents
Numerous studies have found that rural residents are more likely to be uninsured than urban residents. This coverage difference is generally due to more limited access for rural workers to employer-sponsored health insurance. Lower wages, and the tendency for rural residents to work for small employers, account for this reduced access. This study explores the impact of changes in employment status on insurance coverage for rural and urban workers. View or download the Research & Policy Brief or the full report.
Impact of the Opioid Crisis on Rural Emergency Departments

This study used data from the Nationwide Emergency Department Sample (NEDS) and information from a panel of rural emergency care experts to assess the impact of the opioid crisis on rural emergency departments (EDs). Findings will help inform policies designed to help rural health care systems and communities address the growing problem of opioid abuse. Completed publication:

FMI: Jean Talbot, PhD, MPH ( or Erika Ziller (

Implications of Mental Health Comorbidity and Rural Residence for Health Care Use Patterns of Individuals with Chronic Disease
This study used the 2005-2010 panels of the Medical Expenditure Panel Survey to compare the prevalence of concurrent mental health and chronic illnesses across rural and urban populations and to describe relationships among comorbidity, residence, and healthcare use. Findings will inform public and private decisions on how best to allocate new resources available for mental health/primary care integration efforts. The resulting policy brief examined patterns of diabetic preventive care use among adults with diabetes to determine whether these patterns vary according to respondents’ rural/urban residence or the presence/absence of a mental health diagnosis. View or download the Research & Policy Brief.
Issues Related to Rural Health Clinic (RHC) Participation in CMS’s Merit-Based Incentive Payment System (MIPS).
This qualitative project focused on understanding the reporting requirements for RHCs related to CMS’ Merit-Based Incentive Payment System as well as the challenges in doing so and options to support RHC reporting. View or download the Research & Policy Brief.
Knowledge of Health Insurance Concepts and the Affordable Care Act among Rural Residents
Health insurance literacy is central to identifying eligibility for coverage and subsidies, choosing a plan, and using optimal healthcare services. This study examined rural-urban differences in knowledge and/or use of the Affordable Care Act Marketplaces; subsidies; the health insurance mandate; and health insurance terms and concepts. View or download the Research & Policy Brief.
Out-of-Pocket Costs Among Rural Medicare Beneficiaries
Twenty-one percent of individuals covered by Medicare live in rural counties. Although Medicare provides near-universal coverage for seniors, and is an important source of health insurance for individuals with disabilities, many face gaps between the care they need and the costs Medicare will cover. These gaps can be damaging to beneficiaries financial well-being, and put them at risk of problems accessing health care services. This study evaluated rural-urban differences in out-of-pocket spending, supplemental coverage, and variation in spending by type of service. View or download the Research & Policy Brief or the full report.
Patterns of Care for Rural and Urban Children with Mental Health Problems
This study assessed whether use of office-based care and psychotropic medicine by children differs between rural and urban areas, as well as the role of insurance coverage and availability of mental health providers on use of these services. View the report here.
Prevalence and Impact of High Deductible Health Insurance Plans in Rural Areas
Using the 2007-2010 National Health Interview Survey, this study examines rural residents’ enrollment in high deductible health plans and the implications for evolving Affordable Care Act Health Insurance Marketplaces. View or download the Research & Policy Brief or full report.
Preventive Health Service Use Among Rural Beneficiaries.

Preventive health services and screenings are an important component in the continuum of care provided to individuals across all ages. Yet, research has shown that rural residents use fewer preventive health services and screenings.This study used the National Health Interview Survey to examine receipt of preventive health services (cholesterol check, fasting blood sugar test, mammogram, pap smear, and receipt of the HPV vaccine) by rural and urban women over the age of 18. Findings indicate that rural women were less likely than their urban peers to receive preventive health services, and that some of the differences may be explained by rural-urban differences in sociodemographic characteristics. However, even when controlling for these characteristics, lower use of mammogram or HPV vaccine among rural remained. Outreach efforts targeted to rural women, along with policies and programs designed to improve access to rural women’s cancer screening and HPV participation, are needed. A recent Research & Policy Brief has been published and is cited in the Rural Health Research Gateway’s April 2019 Research Recap: State of Women’s Healthcare Utilization and Health Indicators..

FMI: Erika Zilller, PhD

Provision of Specialty Mental Health Services by Rural Health Clinics
This study examined changes in the delivery of mental health services by rural health clinics (RHCs), their operational characteristics, barriers to the development of services, and policy options to encourage more RHCs to deliver mental health services. View or download the Research & Policy Brief or the full report.
Role and Early Impact of CO-OPs in the Rural Health Insurance Marketplace.
The purpose of this study is to fill the knowledge gap about the extent to which CO-OP plans are participating in rural markets, their relative costs compared to other products, the challenges that CO-OPs have faced in reaching rural areas, and the strategies used to address these challenges. Using a mixed-method approach, we will combine quantitative analysis of administrative data with targeted case studies to examine the rural availability and pricing of CO-OP plans, and the early experiences of these plans. Findings will provide important information about the early availability, price-competitiveness, and implementation experience of these CO-OP plans as they have sought to serve rural markets and consumers under the ACA. View or download the Research & Policy Brief.
Rural Demography and Aging: The LTSS Imperative in Rural America.
In the coming decades, the older adult population of the United States is projected to expand significantly. This demographic shift will pose challenges for the nation’s health care and long term services and supports (LTSS) systems. Rural areas are likely to experience a disproportionate share of this growth, due to existing rural infrastructure deficits and the relatively high needs of rural elders. In order to help rural communities meet the increased demand for health/LTSS services, rural stakeholders and policymakers will benefit from having a current, broad-ranging, detailed profile of health care/LTSS needs and use patterns among rural and urban older adults. The proposed project aims to create such a profile through a literature review and analysis of data sets including the American Community Survey, the Area Health Resource File, and the Medicare Current Beneficiary Survey. Findings from this project on the characteristics of the “oldest-old” are available in a Research & Policy Brief available for viewing or download.
Rural E-Mental Health: Models That Enhance Access, Service Delivery, and Integration of Care
E-mental health programs have been developed in rural areas as a promising approach to address the chronic challenges of low availability of mental health clinicians, long travel distances, and stigma surrounding mental health care. The literature has established the technical feasibility of these programs and interest remains strong in developing and implementing them more broadly. However, we lack a clear understanding of the viability of current rural e-mental health programs – both the business case for starting and sustaining them and the clinical case for what services and functions may be provided _ and what impact they have had. The current rural health environment is changing significantly and it is important to understand where and how e-mental health programs have been established and sustained, what impact they have had, and what value they may add to other initiatives. This policy brief describes the organizational setting, services provided, and staff used in 53 telemental rural health programs. It also outlines the opportunities and challenges for telemental health in the rural health system. View or download the Research & Policy Brief. This project also produced a peer-reviewed journal article on the business case for telemental health in rural communities: Lambert, D., Gale, J., Hartley, D., Croll, Z., & Hansen, A. (2016). Understanding the business case for telemental health in rural communities. Journal of Behavioral Health Services and Research, 43(3), 366-379. doi: 10.1007/s11414-015-9490-7
Rural Health Clinic Financial Performance and Productivity

This study used Medicare cost reports for independent and provider-based clinics to provide a detailed national picture of the financial and operational performance of Rural Health Clinics (RHCs) and described variations in performance related to revenue, costs, staffing, payer mix, productivity levels, and hours of operation across independent and provider-based clinics. The project is completed.  The Research & Policy Brief examines the costs of RHCs relative to Medicare payment limits for different types and sizes of RHC providers. 

To view or download the Research & Policy Brief, please visit:

FMI: John Gale, MS

Rural Health Clinics Chartbook

The Rural Health Clinic (RHC) Program, established in December 1977 by the Rural Health Clinic Services Act, P.L. 95-210, is one of the nation’s oldest rural health support programs. RHCs were developed to address geographic primary care access barriers experienced by Medicare and Medicaid populations living in rural underserved areas. RHCs are an important source of primary care services in rural areas with 4,888 RHCs serving the residents of 45 states as of September 2021, and have come to be recognized for their role in serving vulnerable rural populations.

Community Characteristics and Financial and Operational Performance of Rural Health Clinics in the United States: A Chartbook  builds on our extensive body of work on RHCs and our 2003 RHC Chartbook providing an overview of Rural Health Clinic (RHC) characteristics and issues using data from CMS’s Provider of Services file, Medicare Cost Reports, and the Robert Wood Johnson Foundation’s’ County Health Ranking.  The Chartbook provides a discussion of the challenges related to collection and reporting of RHC quality data and will be useful to policymakers and others interested in the performance of RHCs nationally. It can also be useful to RHC administrators to benchmark staffing patterns, productivity, and efficiency.

FMI: John Gale, MS (

Rural Maternal Smoking Behaviors
This study finds rural mothers are more likely than urban mothers to smoke. The authors suggest policymakers consider extending insurance for smoking cessation programs through the Affordable Care Act and Medicaid. Programs at the local, state, and national levels also could help reduce disparities in smoking-related morbidity and mortality. View or download the Research & Policy Brief.
Rural Mental Health First Aid Evaluation.
This project is a mixed-methods case study that focuses on the Mental Health First Aid training program, with a view toward clarifying the rural reach, feasibility, impact, and appropriateness of the program for rural communities.This project is complete and a  journal article has been published in the Journal of Rural Health.
Rural Residential Care: The Implications of Federal and State Policy
In rural communities, residential services provide an important alternative to institutional services, compensating for the fewer available in-home supports. However, rural residential settings have been found to offer less privacy and to be less likely to support aging in place. This study used the National Survey of Residential Care Facilities to evaluate rural and urban differences in the characteristics of residential care facilities and their residents and to assess differences in the impact of these policies on urban and rural residential care service options.The resulting chartbook offers information on part of the rural long-term services and supports (LTSS) continuum—the residential care facility (RCF). Survey results identify national/regional differences between rural and urban RCFs, focusing on facilities, resident and service characteristics of RCFs, and the ability to meet the LTSS needs of residents. View or download the Chartbook.
Safety Net Activities of Independent Rural Health Clinics
Rural Health Clinics (RHCs) provide primary care services to rural residents of 45 states. Since RHCs are in underserved rural areas and serve vulnerable populations, many consider them safety net providers. In this paper, we explore whether, and to what extent, independent RHCs are serving a safety net role or have the capacity to do so. This national study investigated and described the safety net role of independent Rural Health Clinics (RHC), examining the market effect of Federally Qualified Health Centers (FQHC) on the safety net role of independent RHCs at the county level. View or download the Research & Policy Brief or the full report.
Tobacco Treatment in Rural Primary Care

Tobacco use is related to 440,000 deaths each year, making it the leading cause of preventable death and disease in the U.S. Though tobacco use declined from 43% in 1965 to 18% in 2014 among the general U.S. population, tobacco use remains high among several vulnerable subpopulations, in particular, residents of rural areas. Primary care is an important resource in tobacco prevention, but little is known about the degree to which rural primary care providers counsel or prescribe medications for smoking cessation. Using data from the National Ambulatory Medical Care Survey, we compared rural and urban rates and predictors of tobacco counseling and treatment medication prescribing by primary care providers. 

This study was published in the Journal of Rural Health and compares the performance of rural and urban primary care providers in adhering to evidence-based smoking-related standards of care and assesses the degree to which electronic health record use was related to improved adherence to these standards in the practice of rural versus urban providers.

Talbot, J. A., Ziller, E. C., & Milkowski, C. M. (2021, September). Use of Electronic Health Records to Manage Tobacco Screening and Treatment in Rural Primary Care. Journal of Rural Health, online.

Transformation of Rural Health Clinics: Are They Ready to Service as Patient-Centered Medical Homes?
This project examined: 1) the capacity of Rural Health Clinics (RHCs) to serve as Patient -Centered Medical Homes (PCMHs), looking at their health information technology, technical knowledge, and quality, administrative, and clinical systems; 2) the extent to which RHCs have implemented care delivery and practice management features (i.e., care management, team-based practice, patient tracking, clinical-decisions support tools, after-hours care, etc.) of the PCMH model; 3) the quality improvement infrastructure of RHCs; and 4) the technical assistance and resources needed by RHCs to implement the PCMH model. View or download the Research & Policy Brief or the full report.
Understanding Differences in Rural and Urban Adolescent and Young Adult Substance Use.

Recent research suggests that rates of adolescent alcohol, tobacco, and illicit drug use are on the decline. Early results from the 2016 Monitoring the Future annual survey show a continued long-term decline in adolescent substance use across marijuana, alcohol, tobacco, and misuse of some  drescription medications. This project examines rural-urban differences in substance use among adolescents and young adults using data from the 2008-10 and 2014-16 National Survey on Drug Use and Health. Early findings revealed large rural-urban differences in cigarette use by adolescents so our first set of analyses examined change in cigarette use over time, and we presented these findings in a poster at the 2018 National Rural Health Association meeting, and published an article in the American Journal of Public Health.

FMI: Erika Ziller, PhD