The Rural/Urban Impact of Insurance Coverage Changes

Research center:
Lead researchers:
Project funded:
September 2017
Project completed:
August 2019

Access to health insurance coverage has changed over the past several years including through individual and employer mandates, insurance marketplaces, and Medicaid expansions. However, relatively little is known regarding differences in the effects of these coverage changes on health services use and health outcomes between rural and urban areas. Because rural areas face more constraints than urban areas (e.g., coverage, income, distance, availability and distribution of providers), we expect differential effects in terms of changes in coverage as well as coverage impacts on healthcare use and health outcomes by rural/urban status.

This project used existing national datasets to identify the effects of recent changes in both private and public insurance systems on healthcare utilization and health outcomes separately for rural and urban areas. Furthermore, we evaluated heterogeneity across demographic (e.g., age) and socioeconomic factors (e.g., income and education) within rural and urban areas. This effort is the most comprehensive work to date to examining overall effects of recent changes in health insurance coverage on a range of meaningful healthcare use and health outcomes. We employed quasi-experimental designs and advanced econometric models including difference-in-differences (DD) and triple difference (difference-in-difference-in-differences or DDD) to identify causal effects from recent public and private insurance expansions separately by rural/urban status as detailed below. In addition, we stratified models by key demographic and socioeconomic factors separately for individuals in rural versus urban areas. We evaluated multiple healthcare use outcomes including physician visits, outpatient visits, hospital admissions, emergency department visits, and prescription drug use. We also examined multiple health and health behavior outcomes including self-reported physical and mental health status, body weight, and smoking.