Erika Ziller, MS

Phone: 207.780.4615
Fax: 207.780.4417
E-mail: eziller@usm.maine.edu

Maine Rural Health Research Center
University of Southern Maine
Muskie School of Public Service
PO Box 9300
Portland, ME 04104

Current Projects (4)

Challenges and Opportunities for Improving Rural Long-Term Services and Supports under the Affordable Care Act
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Aging, Health policy, Long term care
This project will examine strategies, models, and policy options for improving access to, and quality of, rural long-term services and supports. Through focused policy analyses, we will highlight the rural options, opportunities, and barriers of implementing the coordinated care, health home, and long-term services and supports provisions in the Affordable Care Act.

Health Insurance Stability among Rural Children Following Public Coverage Expansions
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Children, Health insurance and the uninsured, Medicaid and S-CHIP
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 is to investigate changes in insurance stability among rural and urban children following CHIP, and whether this is affected by specific state eligibility and enrollment policies or clusters of policies. Using the 1996, 2001, and 2004 panels of the Survey of Income and Program Participation (SIPP), we will measure rural-urban differences in uninsured spell length and frequency, sources of coverage before and after uninsured spells, movement between sources of coverage, how these measures of stability have changed over time, and the factors that relate to greater continuity of coverage among rural children.

Out-of-Pocket Costs Among Rural Medicare Beneficiaries
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Disabilities, Health policy, Medicare
The purpose of this project is to examine out-of-pocket spending among Medicare beneficiaries, to identify whether there are rural-urban differences in out-of-pocket costs, and to explore what factors account for these differences. Should Medicare redesign occur, this study will provide important information against which to assess the possible impact of different design options on rural Medicare beneficiaries.

Prevalence and Impact of High Deductible Health Insurance Plans in Rural Areas
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health disparities, Health insurance and the uninsured
This study will use national health survey data to examine whether privately insured rural residents are more likely than their urban counterparts to have plans with high deductibles. It will also assess whether high deductible health plans create health care barriers for rural residents, and if these differ from the barriers experienced by those in urban areas.

Completed Projects (7)

Expanding Rural Health Insurance Coverage: How Do Insurance Reform Strategies Stack Up?, Lead researcher
Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
Funder: Office of Rural Health Policy (ORHP)
Topics: Health insurance and the uninsured, Health policy
This purpose of this study is to inform policymakers about the current state of health insurance coverage in rural America, and to assess how specific reform strategies may differentially affect rural residents. Using a combination of analytic strategies, we will provide policymakers and rural health advocates with the necessary tools to develop reform strategies that meet the needs of rural residents.

Financial Impact of Mental Health Services on Rural Individuals and Families, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Health care financing, Health insurance and the uninsured, Mental health
This project will use the Medical Expenditure Panel Survey (MEPS) to examine the financial burden that rural residents face in seeking mental health services, compared to urban residents. Implications of financial burden for access to needed mental health services for rural residents will be assessed.

Health Insurance Dynamics of Uninsured Rural Families
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Health insurance and the uninsured
To better understand the dynamics of insurance coverage among rural and urban families, this study will use the Medical Expenditure Panel Survey (MEPS) to compare family health insurance coverage among non-elderly rural and urban families.

Impact of Employment Transitions on Health Insurance Coverage of Rural Residents, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Health insurance and the uninsured
This project aims to examine rural-urban differences in the proportion of employed adults with private health insurance who experience an employment transition (defined as a change in jobs or hours worked, or no job) and the impact of that change on health insurance status.

Impact of Mental and Emotional Stress on Rural Employment Patterns, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Mental health
This study will use the National Longitudinal Survey of Youth to investigate how mental health symptoms affect employment patterns, and the extent to which these effects differ by rural and urban residence.

Measuring Rural Underinisurance, Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topic: Health insurance and the uninsured

Rural-Urban Differences in Access to Children's Mental Health Services , Lead researcher
Research center: Maine Rural Health Research Center
Funder: Office of Rural Health Policy (ORHP)
Topics: Children, Health services, Mental health
This study uses data from the Urban Institute's National Survey of America's Families to examine and compare the use of mental health services by rural and urban children, age 6 to 17, relative to their need for mental health care, family income, and insurance status.

Publications (25)

Access to Mental Health Services and Family Impact of Rural Children with Mental Health Problems
Author(s): Jennifer D. Lenardson, Erika C. Ziller, David Lambert, Melanie M. Race, Anush Yousefian
Research center: Maine Rural Health Research Center
Topics: Children, Mental health
Report Number: #45
Date: 10 / 2010
Mental health problems have considerable impact on children and their families and some of these impacts are higher in rural than urban areas. Rural children are slightly but significantly more likely to have a mental health problem than urban children, are more likely to have a behavioral difficulty, and are more likely to be usually or always affected by their condition. Compared to urban children, rural children are more likely to go without access to all parent-reported needed mental health services and their families spend more time coordinating their care.
Designing a Prescription Drug Benefit for Rural Medicare Beneficiaries: Principles, Criteria, and Assessment
Author(s): Andrew F. Coburn, Erika C. Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
Topics: Medicare, Medicare Part D, Pharmacy and prescription drugs
Date: 08 / 2000
The purpose of this paper is to offer a rural perspective on the current debate over the design and implementation of a Medicare prescription drug benefit. Background information on rural Medicare beneficiaries' need for, and access to, prescription drugs is provided, along with a set of rural-oriented principles for use in evaluating how different prescription drug proposals may meet the needs of rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
Diabetes and the Rural Safety Net
Author(s): David Hartley, Erika Ziller, Caroline Macdonald
Research center: Maine Rural Health Research Center
Topics: Chronic diseases and conditions, Health insurance and the uninsured
Report Number: Working Paper No. 28
Date: 01 / 2002
Investigates the extent to which the rural safety net is able to meet the needs of people with diabetes. Finds that small rural communities have a relatively greater need for safety net services to diabetics than their urban counterparts. To provide the needed array of services, medications, and support, a coordinated, team approach to care is needed. Such an approach would include the following elements: insurance coverage would be consistent with the standards of care; team management and care coordination would be facilitated, and the informal safety net would be formalized.
Health Care Access and Use Among the Rural Uninsured (Policy Brief)
Author(s): Erika C. Ziller, Jennifer D. Lenardson, Andrew F. Coburn
Research center: Maine Rural Health Research Center
Topics: Health insurance and the uninsured, Health services
Date: 11 / 2011
Using data from the 2002-2007 Medical Expenditure Panel Survey (MEPS), this study examined access to care and service use among non-elderly, uninsured rural and urban residents. Key Findings include:
- Uninsured residents of both rural and urban areas face serious barriers to care compared to those with health insurance coverage.
- The rural uninsured are more likely to have a usual source of care and to have used ambulatory care in the past year than the urban uninsured.
- Insured or not, rural residents have difficulty accessing after hours care and traveling to see their usual provider
Health Insurance Coverage Of The Rural And Urban Near Elderly
Author(s): Erika C. Ziller, Andrew F. Coburn
Research center: Maine Rural Health Research Center
Topics: Aging, Health insurance and the uninsured
Report Number: Working Paper No. 27
Date: 10 / 2003
Reports the results of a study that used data from the 1996-1998 Medical Expenditure Panel Survey (MEPS) to address two principal research questions related to health insurance coverage for the rural near elderly. Findings indicate that the rural near elderly are both more likely to be uninsured and to be in fair or poor health, and when the near elderly become uninsured they may have a much more difficult time regaining health insurance than younger groups. This issue may be even more problematic in rural areas as the findings indicate that 14% of the rural near elderly are uninsured for the entire survey year, compared to 10% of the urban near elderly.
Health Insurance Profile Indicates Need to Expand Coverage in Rural Areas (Policy Brief)
Author(s): Jennifer Lenardson, Erika Ziller, Andrew Coburn, Nathaniel Anderson
Research center: Maine Rural Health Research Center
Topics: Health insurance and the uninsured, Health policy
Date: 07 / 2009
Rural residents-particularly in the most remote rural communities-are in greater need of health reform, as demonstrated by an uninsured rate higher than that of urban residents. The rural-urban disparity in coverage is driven by higher uninsured rates among rural adults, a group that should be part of any strategic effort to improve coverage. This brief provides information on the health insurance status of rural Americans, summarized from a more detailed chartbook. Analyses are based on the 2004-05 Medical Expenditure Panel Survey.
Impact of Employment Transitions on Health Insurance Coverage of Rural Residents
Author(s): Nathaniel J. Anderson, Erika C. Ziller, Melanie M. Race, Andrew F. Coburn
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Report Number: #46
Date: 10 / 2010
Explores the impact of changes in employment status on insurance coverage for rural and urban workers.
Improving Prescription Drug Coverage for Rural Medicare Beneficiaries: Key Rural Considerations and Objectives for Legislative Proposals
Author(s): Andrew F. Coburn, Erika Ziller, Charles W. Fluharty, J. Patrick Hart, A. Clinton MacKinney, Timothy D. McBride, Keith J. Mueller, Rebecca T. Slifkin, Mary K. Wakefield
Research centers: Maine Rural Health Research Center, Rural Policy Research Institute (RUPRI) Center for Rural Health Policy Analysis
Topics: Legislation and regulation, Pharmacy and prescription drugs
Date: 06 / 2000
This Policy Paper combines the work from current projects of the Maine Rural Health Research Center (MRHRC) and the Rural Health Panel of the Rural Policy Research Institute (RUPRI) to provide a statement of specific rural considerations and objectives for any proposal that would add a prescription drug benefit to the Medicare program. Our intent is to establish a framework for assessing the effects of proposals on rural beneficiaries. Report produced by the RUPRI Rural Health Panel.
Many Urban and Rural Workers Lose Health Insurance During Job Transitions (Policy Brief)
Author(s): Nathaniel J. Anderson, Erika C. Ziller, Melanie M. Race, Andrew F. Coburn
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Date: 10 / 2010
Explores the impact of changes in employment status on insurance coverage for rural and urban workers, and the factors behind any differences.
Mental Health Encounters in Critical Access Hospital Emergency Rooms: A National Survey
Author(s): David Hartley, Erika Ziller, Stephenie Loux, John Gale, David Lambert, Anush Yousefian
Research center: Maine Rural Health Research Center
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
Report Number: Working Paper No. 32
Date: 09 / 2005
Investigates the extent and types of cases that present with mental health problems in Critical Access Hospitals (CAHs) emergency rooms (ERs), as well as the resources available to ER staff for addressing such problems and what actually happens to such patients. Emergency department managers in a random sample of 422 CAHs in 44 states completed a telephone survey (response rate = 84.7%) responding to questions about prevalence of mental health problems in their ER and what options they had for responding to such problems. On average, CAHs had 99 emergency room visits per week. Of these visits, 9.4% were mental health related. CAH ERs play a significant role in providing mental health services to rural residents. Although nearly 20% of mental health encounters result in transfers to other facilities, over 40% of mental health problems are addressed on-site through treatment or referrals. Nearly half (43%) of CAH ER managers reported having no access to local mental health providers of any kind.
Mental Health Problems Have Considerable Impact on Rural Children and their Families (Policy Brief)
Author(s): Jennifer D. Lenardson, Erika C. Ziller, David Lambert, Melanie M. Race, Anush Yousefian
Research center: Maine Rural Health Research Center
Topics: Children, Mental health
Date: 10 / 2010
Mental health problems have considerable impact on children and their families and some of these impacts are higher in rural than urban areas. Rural children are slightly but significantly more likely to have a mental health problem than urban children, are more likely to have a behavioral difficulty, and are more likely to be usually or always affected by their condition. Compared to urban children, rural children are more likely to go without access to all parent-reported needed mental health services and their families spend more time coordinating their care. This policy brief provides information on prevalence of children's mental health needs and associated access to care and family impact across rural and urban areas. Analyses are based on the 2005-06 National Survey of Children with Special Health Care Needs.
Out-of-Pocket Health Care Spending and the Rural Underinsured
Author(s): Erika Ziller, Andrew Coburn, Anush Yousefian
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Report Number: Working Paper No. 33
Date: 12 / 2005
Reports the results of a study to identify whether and to what extent there are rural-urban differences in underinsured rates among the privately insured, and, where differences exist, to understand what characteristics of rural residents are related to their likelihood of being underinsured. Using the 2001 and 2001 Medical Expenditure Panel Survey (MEPS), the authors examined the annual out-of-pocket health care expenditures for U.S.residents under age 65 that were continuously insured by a private plan in either 2001 or 2002. Findings showed that, despite having private health insurance coverage, those who use medical services continue to pay for a substantial portion of their own health care costs, particularly those living in rural areas. The average rural non-adjacent individual paid for 39% of their care in 2001 or 2002, compared to 35% for rural adjacent and 32% for urban individuals. Additional findings showed that one out of eight non-adjacent residents is underinsured (12.4%), compared to 10% of rural adjacent and 7% of urban residents.
Out-Of-Pocket Health Spending And The Rural Underinsured
Author(s): Erika C. Ziller, Andrew F. Coburn, Anush E. Yousefian
Research center: Maine Rural Health Research Center
Topics: Health insurance and the uninsured, Rural statistics and demographics
Citation: Health Affairs, 25(6), 1688-1699
Date: 2006
Estimates underinsurance rates among privately insured rural residents and the characteristics associated with rural underinsurance.
Patterns of Health Insurance Coverage Among Rural and Urban Children
Author(s): Andrew F. Coburn, Timothy McBride, Erika Ziller
Research center: Maine Rural Health Research Center
Topics: Children, Health insurance and the uninsured
Report Number: Working Paper No. 26
Date: 11 / 2001
Assesses differences in the patterns of insurance coverage and uninsured spells among rural and urban children in 20 states. Also examines the implications of those differences for the design and implementation of public insurance programs. Among its findings: Although the average duration of new uninsured spells was shorter among rural than urban children, rural children were more likely to experience protracted spells of uninsurance. Rural children were also 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.
Private Health Insurance in Rural Areas: Challenges and Opportunities (Policy Brief)
Author(s): Erika Ziller, Andrew Coburn
Research center: Maine Rural Health Research Center
Topics: Health insurance and the uninsured, Health policy
Date: 04 / 2009
Rural residents are less likely than their urban counterparts to have private health insurance coverage. This difference is driven by the unique characteristics of rural places that make it challenging to create and sustain viable private insurance pools, including the predominance of small businesses and self employed, part time, and low wage workers. This brief discusses the challenges of expanding private coverage in rural areas, and describes policy options to address them.
Profile of Rural Health Insurance Coverage: A Chartbook
Author(s): Jennifer D. Lenardson, Erika C. Ziller, Andrew F. Coburn, Nathaniel J. Anderson
Research center: Maine Rural Health Research Center
Topics: Health insurance and the uninsured, Health policy
Date: 06 / 2009
As the nation considers whether and how to reform the healthcare system, it is important to consider differences in health insurance coverage for those living in rural and urban areas. Analyses of persons under age 65 from the 2004-05 Medical Expenditure Panel Survey reveal a greater proportion of rural residents than urban residents who are uninsured or covered through public sources, especially among those living in remote areas. Rural adults are at high risk of being uninsured compared to rural children. Uninsured rates are highest among adults over age 50 in the most remote rural places. Compared to urban adults, rural adults are less likely to be in employment situations where private coverage is offered.
Rural Adults Face Parity Problems and Other Barriers to Appropriate Mental Health Care
Author(s): Erika Ziller, Nathaniel Anderson, Andrew Coburn
Research center: Maine Rural Health Research Center
Topic: Mental health
Date: 11 / 2008
Findings suggest that a multi-level approach is essential for meeting the mental health service needs of rural residents.
Key facts include: 8% of rural adults say that they are in "fair" or "poor" mental health versus 6% of urban adults;
Among those using mental health services, rural residents are more likely than urban residents to use medication but not therapy. Practice guidelines for quality mental health treatment recommend that medications be given in combination with therapy;
Both rural and urban adults have greater cost sharing for their mental health care than for their total health care use. The percentages do not differ by residence; however, rural residents may be at greater risk of forgoing mental health care due to costs.
This Research & Policy Brief is based on a longer study by the authors. For more information about this study, please contact Erika Ziller at eziller@usm.maine.edu
Rural Children Don't Receive the Mental Health Care They Need (Policy Brief)
Author(s): David Lambert, Erika C. Ziller, Jennifer D. Lenardson
Research center: Maine Rural Health Research Center
Topics: Children, Mental health
Date: 01 / 2009
Just over one-third of all children with a mental health problem received a mental health visit in the past year. Controlling for other characteristics that affect access to care, rural children are 20% less likely to have a mental health visit than urban children. Having Medicaid or SCHIP increases the likelihood that a child will receive services, and this is pronounced in rural areas.
Rural Coverage Gaps Decline Following Public Health Insurance Expansions (Policy Brief)
Author(s): Erika Ziller, Andrew Coburn
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Date: 02 / 2009
This brief uses the Medical Expenditure Panel Survey (MEPS) to compare the health insurance coverage of rural and urban residents in 1997 and 2005 to assess how uninsured rates and sources of coverage have changed since SCHIP was enacted. The authors also discuss the characteristics of the rural uninsured and the implications for health insurance reform. Rural is defined as living in a non-metropolitan county, as designated by the Office of Management and Budget (OMB). All presented results are statistically significant at p. = .05.
Findings: Between 1997 and 2005, the uninsured rate among rural children declined more dramatically than among urban children, following increases in public health insurance. Public health insurance growth among rural adults was much more modest and uninsured rates remained the same. Nearly 60% of the rural uninsured have family incomes below 200% of the federal poverty level suggesting the potential for expanding public coverage. For those with higher incomes, policy strategies to strengthen private coverage will need to account for the unique employment and insurance market characteristics of rural areas.
Rural Residents More Likely to be Underinsured
Author(s): Erika Ziller
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Report Number: Research and Policy Brief
Date: 2006
Multiple studies have demonstrated that rural residents, particularly those living far from urban areas, have high uninsured rates. However, even those with private health insurance coverage can be at risk of having high out-of-pocket health care costs. Understanding the degree to which rural residents are "underinsured" has important implications for rural health policy and practice.
Rural-Urban Differences in Health Care Access Vary Across Measures
Author(s): Erika Ziller, Jennifer Lenardson
Research center: Maine Rural Health Research Center
Topic: Health services
Date: 06 / 2009
Higher uninsured rates and workforce shortages in rural areas suggest that rural residents face greater barriers to accessing health care than their urban counterparts. Analysis of the 2006 Medical Expenditure Panel Survey found mixed results. Rural residents were more likely than urban residents to have a usual source of health care (USC), particularly among the uninsured. Despite this, rural adults were somewhat less likely to receive certain preventive care services compared to urban adults. Additionally, rural residents were somewhat more likely to report long travel times to reach their USC and greater difficulty in reaching their provider after hours.
Rural-Urban Differences in Work Patterns Among Adults With Depressive Symptoms
Author(s): Lisa Morris, Stephenie Loux, Erika Ziller, David Hartley
Research center: Maine Rural Health Research Center
Topic: Mental health
Report Number: Working Paper #38
Date: 03 / 2008
This study addresses the issue of poor mental health among young to middle-career rural residents and how their employment may be affected. Using the National Longitudinal Survey of Youth (NLSY), a nationally representative survey of adults, the authors investigate how depressive symptoms affect employment patterns, and the extent to which such effects differ by rural and urban residence. Analysis of the data identified the rural sample as more likely to be married, have less education, are less likely to be black or Hispanic, and less likely to have health insurance than the urban sample. For both rural and urban subjects, individuals with depressive symptoms work less than those not depressed. Although the findings indicate no significant difference between depressed rural and urban residents in maintaining employment, questions remain about rural access to mental health services, such as employee assistance, productivity on the job, and the survival or coping strategies of rural workers with depressive symptoms.
State Licensure Laws and the Mental Health Professions: Implications for the Rural Mental Health Workforce
Author(s): David Hartley, Erika C. Ziller, David Lambert, Stephenie L. Loux, Donna C. Bird
Research center: Maine Rural Health Research Center
Topics: Legislation and regulation, Mental health, Workforce
Report Number: Working Paper No. 29
Date: 05 / 2002
Investigates whether and the extent to which licensure laws that determine the permissible scope of practice for each of these professions may affect the availability of mental health services, particularly in rural communities. Findings: Licensure laws authorize non-physician mental health providers to practice assessment, treatment planning, and individual and group counseling independently in most of the 40 states studied. Many states do not explicitly grant the authority to all of these professions for diagnosis or psychotherapy, but none explicitly deny it. Despite this finding, Medicare and some other payers do not directly reimburse Marriage and Family Therapists or Licensed Professional Counselors. Laws that require clinical supervision of newly trained practitioners to be performed exclusively by a member of the profession in a face-to face setting may make it difficult for a new graduate seeking rural practice to log the number of required hours within the specified time limit to qualify for independent practice. Some states' laws allow supervision that is not face-to-face, a rural-friendly policy. Also discussed are the nature and effects of guild behavior in the mental health professions. Based on the findings, report recommends that states simplify licensure and clarify clinical roles by combining regulatory functions for several professions into a single office or agency; that Medicare reconsider its position on reimbursing Marriage and Family Therapists or Licensed Professional Counselors; that professional competition over the right to practice and be reimbursed be addressed; and that supervision requirements be modified to allow new mental health professional graduates to address rural needs soon after graduation.
Uninsured Rural Families
Author(s): Erica Ziller, Andrew F. Coburn, N. Anderson, Stephanie Loux
Research center: Maine Rural Health Research Center
Topic: Health insurance and the uninsured
Report Number: Working Paper No. 34
Date: 2006
Use of Critical Access Hospital Emergency Rooms by Patients With Mental Health Symptoms
Author(s): David Hartley, Erika C. Ziller, Stephenie L. Loux, John A. Gale, David Lambert, Anush E. Yousefian
Research center: Maine Rural Health Research Center
Topics: Critical Access Hospitals and Rural Hospital Flexibility Program, Emergency medical services (EMS), Mental health
Citation: Journal of Rural Health, 23(2), 108-115
Date: 2007
Describes the results of a study investigating the use of critical access hospital (CAH) emergency rooms by patients with mental health problems to understand the role these facilities play in rural mental health needs and the challenges they face.