Rural Healthcare Disparities Are Greatest in US: Study

There are more healthcare disparities between rural and urban residents of the United States than between rural and urban residents of 10 other developed countries, according to a new study published July 7 in JAMA Network Open.

Using data collected by the Commonwealth Fund for its 2020 survey of 11 advanced nations, the researchers analyzed the information for differences between the rural and urban participants in each country, looking at 10 indicators in three domains: health status and socioeconomic risk factors, affordability of care, and access to care.

According to the paper, “The US had statistically significant geographic health disparities in 5 of the 10 indicators, the most of any country, followed by Switzerland (4), the UK and Australia (3 each), and France and Germany (2 each). Canada, Norway and the Netherlands had no statistically significant geographic health disparities.”

The authors of the study said that the results were partly related to the fact that the US is the only one of the 11 countries that doesn’t have a national health system. The other nations included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK.

In an interview with Medscape, lead author Neil MacKinnon, PhD, a professor at the Medical College of Georgia, elaborated on this thesis: “If you have a single-payer system, there’s more consistency across geography,” he said. “In the US, because its system is so different from that of the other countries, there are bigger differences [between rural and urban healthcare] because of payer mix and so forth.”

Not all of the other countries in the study have a single-payer system, but they all have greater governmental control of the healthcare system than the US does. Gerard Anderson, PhD, professor of health policy and management at Johns Hopkins University and professor of international health at John Hopkins School of Medicine, told Medscape that this is the key.

“In the US, there is a huge spending differential between the urban areas and the rural areas,” he noted. “In most of the other countries, they have allocated resources disproportionately to the rural areas in order to make up any differential in access and services…They’re mostly allocating resources on a per-capita basis, whereas the US is not allocating on a per-capita basis. And in some cases, they give extra bonuses to rural areas.”

Anderson cited Denmark as an example of how countries with national healthcare get physicians to practice where they’re needed. “Essentially, they say, we only need this number of ophthalmologists in Copenhagen. So, we’re going to send some of you to other places. if you want a job, you’ll have to be somewhere else other than Copenhagen.”

Worldwide Healthcare Provider Shortage

Not all of the paper’s findings fit into this neat box, however. For example, while Canada is one of the nations that had no urban-rural disparities, there is a serious shortage of clinicians in some rural areas of Canada. In addition to the large size of the country, this may be related to the global shortage of doctors, suggests study co-author Munira Gunja, MPH, senior researcher in the international health policy program of the Commonwealth Fund.

Anderson sees the explanation in the relative population sizes of the countries. “It’s hard in northern Canada or in northern Sweden to provide enough doctors, particularly specialists. Whereas France or even the South Island of New Zealand have a fair number of people. Any country that has large, very rural communities is going to have trouble having enough doctors or nurse practitioners to meet the demand.”

No Differences Seen in Ability to Pay Bills

One counterintuitive finding of the study is that there were no disparities between the urban and rural areas of all countries in people being unable to pay their medical bills or having multiple chronic conditions. Research shows that the US has much higher rates of healthcare unaffordability than other developed countries do, Gunja notes. “So, while there may not be a disparity between rural and urban residents, we’re still much higher in that than other countries.”

The study says the relative sizes of various countries also make comparisons difficult. These differences can make it difficult to even define what a rural area is. “In the Netherlands, only 11.8% of their population is considered rural,” MacKinnon observes. “And even that still looks very different than Montana or Colorado. There are areas in the Netherlands that they consider rural that would be classified as urban in the US.”

Looking at the rural health data in isolation, Germany had the lowest percentages of rural respondents with multiple chronic conditions, mental health conditions, or experiences of material hardship. The US had the highest or one of the highest percentages for all three of those indicators. On affordability, the US had the highest rate for skipping needed care, and Norway and Sweden had the lowest.

An unexpected finding was that, across all 11 countries, rural residence was a protective factor more often than it was a risk factor. “Notably, rural dwellers had greater odds of having a regular clinician or place of care more often than urban dwellers in Germany, France, Switzerland, the UK, and the US. This was surprising, given the shortage of healthcare professionals in rural areas.”

Also surprising was that Switzerland had four occurrences of geographic health disparities, more than any other nation besides the US. Switzerland has the second highest life expectancy in Europe, spends more capita than any European country, and has a health system with high consumer satisfaction, the study points out.

But the bottom line of the research is not surprising, Mackinnon noted: “This study shows that compared to these other nations, the US has a lot more geographic disparities. We usually look at disparities based on ethnicity or race, but here we looked at disparities by zip code. And we’ve got some zip codes in the US where the health outcomes are very poor.”

Co-author Brittany Ange, PhD, reported receiving grants from Augusta University during the conduct of the study. Gunja reported employment with the Commonwealth Fund, a source of funding for this study. No other disclosures were reported.

JAMA Netw Open. Published online July 7, 2023. Full text

Ken Terry is a healthcare journalist and author. His latest book is Physician-Led Healthcare Reform: A New Approach to Medicare for All.

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