Nearly 60 million people in the United States reside in a rural area. Residents in rural
areas have higher rates of chronic disease, risky health behaviors, disability, infant
mortality, and age-adjusted mortality than their urban counterparts. Health insurance and
access to care mitigate those risks, in part because insured persons are more likely to
receive preventive care. Before implementation of the Affordable Care Act (ACA), 16%
of the US population was uninsured. By 2016 the uninsured rate dropped to 10.5%. Many
of those obtained coverage through state Medicaid expansion. It is important to understand how those newly enrolled in Medicaid are utilizing care, especially in more
rural parts of the US where access may be more challenging.
This study examined whether there were differences across levels of rurality in
preventive and behavioral health service utilization among new expansion enrollees in
Oregon compared to those previously enrolled.
This study used a quasi-experimental, retrospective cohort design utilizing: Oregon
Medicaid claims and eligibility, as well as Rural Urban Commuting Areas (RUCAs),
American Community Survey, and Health Resources and Services Administration
Primary Care Service Area data. Linear probability models were used to estimate the
effect of rurality on preventive and behavioral health service utilization among new
versus previous Medicaid enrollees. Additionally, this study examined the effects of
continuity of coverage on health service utilization by level of rurality among those
newly enrolled and previous enrollees. Models controlled for age, sex, race, ethnicity,
eligibility category, chronic conditions, and enrollment in a Medicaid accountable care
organization (Coordinated Vare Organization or CCO) as well as the number of primary
care providers per population, and median home value.