Changes in Medicare Fee-for-Services Health Care Expenditures in Rural and Urban Communities after Passage of the Affordable Care Act

This project assessed changes in Medicare per-beneficiary spending across rural and urban counties from 2007 to 2020. It examined differences in rural versus urban per-beneficiary spending on hospital inpatient, hospital outpatient, physician, and post-acute care after the Affordable Care Act (ACA).

The study conducted a longitudinal quantitative analysis. There were two set of outcomes:

1. County-level price-standardized per-beneficiary expenditures across all service settings and by setting
2. County-level proportions of total Medicare expenditures spent on each service setting

A trend analysis of both sets of the outcomes across counties by levels of rurality from 2007 to 2019 were conducted. The ratio of total expenditures and specific expenditure categories between urban and rural in each year from 2007 to 2019 graphing the results to illustrate pre- and post-ACA differences were calculated.

Z tests were used to compare the following:

• Ratios of rural Medicare expenditures to the urban expenditures in 2007 to the ratios of rural Medicare expenditures to the urban expenditures in 2019 for total per-beneficiary expenditures
• Expenditures in each of the 4 subsets of services (except other services)
• Per-beneficiary expenditures for each of the 3 subcategories of post-acute care services

Publications

• Medicare Fee-for-Service Health Care Expenditures Among Rural and Urban Beneficiaries During 2009-2019
  Policy Brief
  University of South Carolina Rural Health Research Center
  Date: 01/2026
  CMS Medicare Geographic Variation Public Use files, the American Community Survey, and the Area Health Resource files were the data sources for research on whether, and to what extent, rural Medicare beneficiaries used health care differently from their urban counterparts from 2009-2019.