Chapter 4. Priority Populations (continued, 4)

National Healthcare Disparities Report, 2008


Residents of Rural Areas

About one in five Americans lives in a nonmetropolitan area.59 Compared with their urban counterparts, rural residents are more likely to be older, poor,60 and in fair or poor health and to have chronic conditions.59 Rural residents are less likely to receive recommended preventive services and report, on average, fewer visits to health care providers.61

Although 20% of Americans live in rural areas,xv only 9% of physicians in America practice in those settings.62 Nurse practitioners, nurse midwives, and physician assistants also deliver care. Multiple programs and services deliver needed services in rural areas, such as the National Health Service Corps Scholarship Program, Indian Health Service, State offices of rural health, rural health clinics, and community health centers. Cost-based Medicare reimbursement incentives are also available for rural health clinics, critical access hospitals, sole community hospitals, and Medicare-dependent hospitals in health professional shortage areas.

Many rural residents depend on small rural hospitals for their care. There are approximately 2,000 rural hospitals throughout the country,63 1,500 of which have 50 or fewer beds. Most of these hospitals are critical access hospitals that have 25 or fewer beds. Rural hospitals largely provide primary care and chronic disease management. They face unique challenges due to their size and case-mix. During the 1980s, many were forced to close because of financia1 losses;64 however, finances of small rural hospitals have improved and few closures have occurred since 2003.

Transportation needs are pronounced among rural residents, who must travel longer distances to reach health care delivery sites. Of the nearly 1,000 "frontier counties"xvi in the Nation, most have limited health care services and many do not have any.65

Many measures of relevance to residents of rural areas are tracked in the NHDR. Findings presented here highlight four quality measures and one access measure of particular importance to residents of rural areas, with additional geographic data from metropolitan areas:

Component of health care needMeasure
PreventionPrenatal care and maternal health
ManagementRecommended services for diabetes
TreatmentRecommended care for colorectal cancer
TimelinessCare for illness or injury as soon as wanted
Access to careHealth insurance

In previous NHDRs, detailed geographic typologies were applied to two AHRQ databases— MEPS and HCUP—to define variations in health care quality and access for a range of rural and urban locations. This year, in addition to presenting data from MEPS and HCUP, the NHDR presents a measure from the National Vital Statistics System-Natality. Federal definitions of micropolitan and noncore statistical areas (not metropolitan or micropolitan areas) published in June 2003 are used.66 In addition, urban influence codes are used to subdivide metropolitan areas into large and small metropolitan areas. Thus, categories used in this section of the NHDR may be defined as follows:

  • Metropolitan (total): all metropolitan areas.
  • Large central metropolitan statistical area: central counties in metropolitan area of 1 million or more inhabitants.
  • Large fringe metropolitan statistical area: outlying (suburban) counties in metropolitan areas of 1 million or more inhabitants.
  • Medium metropolitan statistical area: counties in metropolitan areas of 250,000-999,999 inhabitants.
  • Small metropolitan statistical area: metropolitan area of 50,000-249,999 inhabitants.
  • Nonmetropolitan (total): all nonmetropolitan areas.
  • Micropolitan statistical area: counties with an urban cluster of at least 10,000 but fewer than 50,000 inhabitants.
  • Noncore statistical area (rural): not metropolitan or micropolitan.

Urban-rural contrasts for measures from MEPS and HCUP compare residents of rural statistical areas (including both micropolitan and noncore statistical areas) with residents of urban statistical areas (including both large central, large fringe, medium, and small metropolitan statistical areas). Sample sizes are often too small to provide reliable estimates for noncore statistical areas, limiting the ability to assess disparities among residents of these areas.


xv Many terms are used to refer to the continuum of geographic areas. For Census 2000, the U.S. Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urban areas and urban clusters. The Census Bureau classified as "urban" all territory, population, and housing units located within (1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and (2) surrounding census blocks that have an overall density of at least 500 people per square mile.
xvi " Frontier counties" have a population density of less than 7 people per square mile; thus, residents travel long distances for care.


Quality of Health Care

Prevention: Prenatal Care and Maternal Health

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care, and childbirth is the most common reason for hospital admission.67 It is recommended that women begin receiving prenatal care in the first trimester of pregnancy.

Figure 4.43. Women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester, selected States, by geographic location, stratified by race (top), ethnicity (middle), and education (bottom), 2005

Bar chart shows percent women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester, selected States, by geographic location, stratified by race, 2005. A summary of the information is provided below.

Bar chart shows percent women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester, selected States, by geographic location, stratified by ethnicity, 2005. A summary of the information is provided below.

Bar chart shows percent women who completed a pregnancy in the last 12 months who first received prenatal care in the first trimester, selected States, by geographic location, stratified by education, 2005. A summary of the information is provided below.

Large Central Metropolitan = central counties in metropolitan areas = 1 million inhabitants.
Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥1 million inhabitants.
Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.
Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.
Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.
Noncore = <10,000 inhabitants.
Key: AI/AN = American Indian or Alaska Native; API = Asian Pacific Islander.
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System-Natality, 20045
Reference population: Women with live births.
Note: Data for 2005 include the 39 reporting areas (37 States, DC, and New York City) that used 1989 revision of the U.S. Standard Certificate of Live Birth in 2005. Reporting areas that have adopted the 2003 revision are excluded because prenatal data based on the 2003 revision are not comparable with data based on 1989 and earlier revisions of the U.S. Standard Certificate of Live Birth.

  • In 2005, there were no significant differences observed between geographic locations in the percentage of women who initiated prenatal care in the first trimester (Figure 4.43).
  • In micropolitan and noncore (rural) areas, there were significant racial and educational disparities. In these areas, Black women were less likely than White women to receive prenatal care (micropolitan, 73.9% compared with 83.2%; noncore, 74.1% compared with 83.4%). In micropolitan areas, APIs were also less likely than Whites to receive prenatal care (73.7% compared with 83.2%). In both areas, women with less than a high school education were less likely than women with at least some college education to receive prenatal care (micropolitan, 67.4% compared with 89.8%; noncore, 66.6% compared with 89.5%).
  • In large central metropolitan areas, there were significant racial and education disparities. In these areas, Black women were less likely than White women to receive prenatal care (75.9% compared with 86.0%). Individuals with less than a high school education (76.7%) and high school graduates (81.9%) were less likely to receive prenatal care than individuals with at least some college education (91.2%).
  • In medium and small metropolitan areas, there were significant ethnic and educational disparities. Hispanic women were less likely than non-Hispanic White women to receive prenatal care (medium, 75.6% compared with 88.5%; small, 68.2% compared with 87.2%). Women with less than a high school education were less likely than women with at least some college education to receive prenatal care (medium, 71.3% compared with 91.2%; small, 68.8% compared with 90.3%).
  • In 2005, only women with at least some college education who lived in metropolitan areas and non-Hispanic White women in large central and large fringe metropolitan areas achieved the Healthy People 2010 target of 90% of women receiving prenatal care in the first trimester.

Management: Recommended Services for Diabetes

The NHDR presents a composite measure that tracks receipt of three recommended services for effective management of diabetes: hemoglobin A1c testing, dilated eye examination, and foot examination in the past year.

Figure 4.44. Composite measure: Adults age 40 and over with diagnosed diabetes who received all three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, dilated eye examination, and foot examination), by geographic location, 2005

Bar chart shows percent adults age 40 and over with diagnosed diabetes who received all three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, dilated eye examination, and foot examination), by geographic location, 2005. Metropolitan (Total): 41.9%; Large Central Metropolitan: 40%; Large Fringe Metropolitan: 43.5%; Medium Metropolitan: 42.5%; Small Metropolitan: 43%; Nonmetropolitan (Total); 35%; Micropolitan: 37%; and Noncore: 31.9%.

Large Central Metropolitan = central counties in metropolitan areas =1 million inhabitants.
Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥1 million inhabitants.
Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.
Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.
Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.
Noncore = <10,000 inhabitants.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population age 40 and over.
Note: Recommended services for diabetes are (1) hemoglobin A1c testing, (2) dilated eye examination, and (3) foot examination. Sample sizes were too small to provide estimates by race, ethnicity, income, or education in all areas except metropolitan (total).

  • In 2005, the percentage of diabetes patients who received all three recommended services for diabetes was lower for patients in noncore areas overall than in metropolitan areas (31.9% compared with 41.9%; (Figure 4.44).
  • In metropolitan areas (total), there were significant ethnic, income, and educational disparities (data not shown). Hispanics were less likely than non-Hispanic Whites to receive recommended care for diabetes (33.6% compared with 45.4%). Poor (32.4%), near-poor (31.1%), and middle-income (38.6%) individuals were less likely than high-income individuals (54.6%) to receive recommended care for diabetes. Individuals with less than a high school education were less likely than individuals with at least some college education to receive recommended care for diabetes (33.2% compared with 48.4%).

Treatment: Recommended Care for Colorectal Cancer

Figure 4.45. Patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by geographic location, stratified by race (top), ethnicity (middle), and income (bottom), 2005

Bar chart shows percent patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by geographic location, stratified by race, 2005. Metropolitan (Total): Total, 61; White, 61; Black, 58; Asian, 64.9. Large Metropolitan: Total, 61.5; White, 62; Black, 57.5; Asian: 62. Small Metropolitan: Total, 60.; White, 59.5; Black, 59; Asian: 70.7. Micropolitan: Total, 51.6; White, 51.5; Black, 52; Asian: No data. Noncore: Total, 59.5; White, 59; Black, 61; Asian: No data.

Bar chart shows percent patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by geographic location, stratified by ethnicity, 2005. Metropolitan (Total): Non-Hispanic White, 61; Hispanic, 61. Large Metropolitan: Non-Hispanic White, 61.5; Hispanic, 61.5. Small Metropolitan: Non-Hispanic White, 60; Hispanic, 58. Micropolitan: Non-Hispanic White, 51.6; Hispanic, No data. Noncore: Non-Hispanic White, 59; Hispanic, No data.

Bar chart shows percent patients with colon cancer who received surgical resection of colon cancer that included at least 12 lymph nodes pathologically examined, by geographic location, stratified by income, 2005. Metropolitan (Total): Poor, 58.0; Near Poor, 59.5; Middle Income, 64; High Income, 66.8. Large Metropolitan: Poor, 65; Near Poor, 60; Middle Income, 63; High Income, 66.8. Small Metropolitan: Poor, No data; Near Poor, 58; Middle Income, 66.7; High Income, No data. Micropolitan: Poor, No data; Near Poor, 58; Middle Income, No data; High Income, No data. Noncore: Poor, 58; Near Poor, No data; Middle Income, No data; High Income; No data.

Large Central Metropolitan = central counties in metropolitan areas =1 million inhabitants.
Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥1 million inhabitants.
Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.
Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.
Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.
Noncore = <10,000 inhabitants.
Source: Commission on Cancer, American College of Surgeons and American Cancer Society, National Cancer Data Base, 2005.
Note: Definitions of metropolitan, large metropolitan, small metropolitan, and noncore are based on U.S. Department of Agriculture Economic Research Service 2003 urban influence codes. Data did not meet the criteria for statistical reliability for Asians in micropolitan and noncore areas; Hispanics in micropolitan and noncore areas; high-income individuals in small metropolitan, micropolitan, and noncore areas; middle-income individuals in micropolitan and noncore areas; poor individuals in small metropolitan and micropolitan areas; and near-poor individuals in noncore areas.

  • There are statistically significant differences among geographic locations in the percentage of colon cancer patients who received recommended treatment. Patients in micropolitan areas (51.6%) were less likely to receive recommended treatment than patients in metropolitan areas (61.0%; Figure 4.45).
  • In small metropolitan areas, Asian patients with colon cancer were more likely than White patients with colon cancer to receive recommended treatment (70.7% compared with 59.5%).
  • In metropolitan areas, the overall percentages of poor patients with colon cancer (58.0%) and near-poor (59.5%) patients who received recommended treatment were lower than the percentage of high-income patients (66.8%).
  • Findings for other geographic locations and other comparisons were not statistically significant.

Timeliness: Care for Illness or Injury as Soon as Wanted

Timely delivery of appropriate care has been shown to improve health care outcomes and reduce health care costs. In addition, when patients need or want care, having access to that care improves their health care experience, which may further promote health.

Figure 4.46. Adults who who needed care right away for an illness, injury, or condition last 12 months who sometimes or never got care as soon as wanted, by geographic location, stratified by income (top) and education (bottom), 2005

Bar chart shows percentage of adults who needed care right away for an illness, injury, or condition last 12 months who sometimes or never got care as soon as wanted, by geographic location, stratified by income, 2005. Metropolitan (Total): Total, 16; Poor, 26.0%; Near Poor, 20%; Middle Income, 15%; High Income, 10.5%. Large Central Metropolitan: Total, 16.5%; Poor, 26.0%; Near Poor, 18%; Middle Income, 16%; High Income, 10.4%. Large Fringe Metropolitan: Total, 16.5%; Poor, 26.5%; Near Poor, 20%; Middle Income, 17%; High Income, 11%. Medium Metropolitan: Total, 15; Poor, 24%; Near Poor, 23%; Middle Income, 12%; High Income, 9.5%. Small Metropolitan: Total, 15%; Poor, No data; Near Poor, 19%; Middle Income, 14%; High Income, No data. Nonmetropolitan (Total): Total, 15%; Poor, 19.0%; Near Poor, 18%; Middle Income, 13%; High Income, 9.4%. Micropolitan: Total, 15.5%; Poor, 20%; Near Poor, 22%; Middle Income, 12%, High Income, No data. Noncore: Total, 11%; Poor, No data; Near Poor, no data; Middle Income, 10%; High Income, No data.

Bar chart shows percentage of adults who needed care right away for an illness, injury, or condition last 12 months who sometimes or never got care as soon as wanted, by geographic location, stratified by education, 2005. Metropolitan (Total): Less than High School, 21.2%; High School Grad, 14.7%; Some College, 13.5%. Large Central Metropolitan: Less than High School, 21%; High School Grad, 14.5%; Some College, 16%. Large Fringe Metropolitan: Less than High School, 21%; High School Grad, 15%; Some College, 14.5%. Medium Metropolitan: Less than High School, 20.5%; High School Grad, 13%; Some College, 14.5%. Small Metropolitan: Less than High School, 23%; High School Grad, 20; Some College, 8%. Micropolitan: Less than High School, 21.2%; High School Grad, 10.5%; Some College, 13%. Noncore: Less than High School, 19.8%; High School Grad, No data; Some College, No data.

Large Central Metropolitan = central counties in metropolitan areas =1 million inhabitants.
Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥1 million inhabitants.
Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.
Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.
Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.
Noncore = <10,000 inhabitants.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population age 18 and over.
Note: Data are not available for all income or education groups in noncore areas. Data are not available for poor and high-income groups in small metropolitan areas or for high-income groups in micropolitan areas.

  • There were no significant differences observed between geographic locations in the overall rate of adults who sometimes or never get care for illness or injury as soon as wanted (Figure 4.46).
  • There were significant differences by income in nonmetropolitan areas. Poor (19.0%), and near-poor (18.0%) individuals were more likely than high-income individuals (9.4%) to sometimes or never get care for illness or injury as soon as wanted in these areas.
  • Differences by education were also observed in nonmetropolitan areas. In micropolitan areas, individuals with less than a high school education (21.2%) were more likely than individuals with at least some college education (12.1%) to sometimes or never get care for illness or injury as soon as wanted.
  • There were significant differences by income in metropolitan locations. Poor, near-poor, and middle-income individuals were more likely than high-income individuals to sometimes or never get care for illness or injury as soon as wanted in large central metropolitan and large fringe metropolitan areas.
  • There were also some differences by education in metropolitan locations. Individuals with less than a high school education were more likely than individuals with at least some college education to sometimes or never get care for illness or injury as soon as wanted in small and medium metropolitan areas.

Access to Health Care

Health Insurance

Access to health care is a prerequisite to receipt of care, yet many Americans still face barriers to care. Data for prolonged periods of uninsurance (no insurance coverage for a full year) are presented.

Figure 4.47. Adults under age 65 uninsured all year, by geographic location, stratified by race (top), ethnicity (second down), income (third down), and education (bottom), 2005

Bar chart shows percentage of adults under age 65 uninsured all year, by geographic location, stratified by race, 2005. Some of the highlights are described below.

Bar chart shows percentage of adults under age 65 uninsured all year, by geographic location, stratified by ethnicity, 2005. Some of the highlights are described.

Bar charts show percentage of adults under age 65 uninsured all year, by geographic location, stratified by income, 2005. Some of the highlights are described below.

Bar charts show percentage of adults under age 65 uninsured all year, by geographic location, stratified by education, 2005. Some of the highlights are described below.

Large Central Metropolitan = central counties in metropolitan areas =1 million inhabitants.
Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥1 million inhabitants.
Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.
Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.
Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.
Noncore = <10,000 inhabitants.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population age 18 and over.
Note: Estimates for Asians in small metropolitan, nonmetropolitan, micropolitan, and noncore areas did not meet criteria for statistical reliability and are not reported here.

  • There were statistically significant differences within metropolitan areas in the percentage of adults under age 65 who were uninsured all year (lowest percentage of uninsured overall was in large fringe metropolitan areas, 11.1%; Figure 4.47), as well as between metropolitan and nonmetropolitan areas. In metropolitan areas, small metropolitan areas had a higher percentage of adults who were uninsured than large fringe metropolitan areas (12.7% compared with 11.1%). In nonmetropolitan areas, micropolitan areas had a higher percentage of adults who were uninsured than large fringe metropolitan areas (13.1% compared with 11.1%).
  • In noncore areas, there were significant ethnic, income, and education disparities. Hispanics were more than twice as likely as non-Hispanic Whites to be uninsured all year (39.0% compared with 16.0%). Poor individuals and near-poor individuals (23.2% and 26.6%, respectively) were more likely than high-income individuals (7.7%) to be uninsured all year. Individuals with less than a high school education (38.5%) and high school graduates (21.4%) were more likely than individuals with at least some college education (12.8%) to be uninsured all year.
  • In micropolitan areas, there were significant racial, ethnic, income, and education disparities. Blacks were more likely than Whites to be uninsured all year (21.2% compared with 12.3%). Hispanics were almost twice as likely as non-Hispanic Whites to be uninsured all year (22.5% compared with 11.4%). Poor individuals (22.9%), near-poor individuals (21.6%), and middle-income individuals (10.9%) were also more likely than high-income individuals (6.1%) to be uninsured all year. Individuals with less than a high school education (30.0%) and high school graduates (15.4%) were less likely than individuals with at least some college education (9.5%) to be uninsured all year.
  • Large central metropolitan areas had significant ethnic and income disparities. In these areas, Hispanics were almost three times as likely as non-Hispanic Whites to be uninsured all year (30.4% compared with 10.6%). Poor individuals (25.2%), near-poor individuals (27.5%), and middle-income individuals (18.1%) were also more likely than high-income individuals (8.7%) to be uninsured all year.
  • Large fringe metropolitan areas had significant ethnic, income, and education disparities. In these areas, Hispanics were more than three times as likely to be uninsured all year (27.8% compared with 8.2%). Poor individuals (23.0%), near-poor individuals (23.6%), and middle-income individuals (13.1%) were also more likely than high-income individuals (4.9%) to be uninsured all year. Individuals with less than a high school education (30.2%) and high school graduates (16.4%) were less likely than individuals with at least some college education (7.5%) to be uninsured all year.
  • Medium metropolitan areas had significant ethnic, income, and education disparities. In these areas, Hispanics were almost three times as likely to be uninsured all year (26.1% compared with 9.6%). Poor individuals (26.8%), near-poor individuals (21.1%), and middle-income individuals (10.8%) were also more likely than high-income individuals (4.2%) to be uninsured all year. Individuals with less than a high school education (30.6%) and high school graduates (16.7%) were less likely than individuals with at least some college education (8.6%) to be uninsured all year.
  • Small metropolitan areas had significant ethnic, income, and education disparities. In these areas, Hispanics were almost twice as likely to be uninsured all year (20.3% compared with 11.7%). Poor individuals (18.7%), near-poor individuals (21%), and middle-income individuals (13.1%) were also more likely than high-income individuals (6.6%) to be uninsured all year. Individuals with less than a high school education (28.7%) and high school graduates (18.3%) were less likely than individuals with at least some college education (9.9%) to be uninsured all year.
Current as of March 2009
Internet Citation: Chapter 4. Priority Populations (continued, 4): National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap4d.html