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Rural-Urban Disparities in Health Care in Medicare


This report presents summary information on the quality of health care received by Medicare beneficiaries nationwide. It uses annual health care data collected in 2019 and references care received since the 2018 data collection. The report highlights (a) rural-urban1 differences in health care experiences and clinical care, (b) how rural-urban differences vary by race and ethnicity, and (c) how racial and ethnic differences vary between rural and urban areas.

The report is based on an analysis of two sources of information. The first source is the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey, which is conducted annually by the Centers for Medicare & Medicaid Services (CMS) and focuses on health care experiences (e.g., ease of getting needed care, how well providers communicate, and getting needed prescription drugs) of Medicare beneficiaries across the nation. The second source of information is the Healthcare Effectiveness Data and Information Set (HEDIS®). HEDIS is composed of information collected from medical records and administrative data on the technical quality of care that Medicare beneficiaries receive for a variety of medical issues, including diabetes, cardiovascular disease, and chronic lung disease. Whereas Medicare CAHPS data are available for beneficiaries enrolled in Medicare fee-forservice (FFS) and managed care (Medicare Advantage [MA]) plans, HEDIS data are available only for beneficiaries enrolled in MA plans.

Rural-Urban Disparities in Health Care in Medicare

With just one exception, both FFS and MA beneficiaries living in rural areas reported health care experiences that were similar to the experiences reported by FFS and MA beneficiaries living in urban areas (see Figure 1). The exception pertained to annual flu vaccination rates, which were higher for urban than for rural FFS and MA beneficiaries. Rural-urban disparities in clinical care were more common: compared with MA beneficiaries living in urban areas, MA beneficiaries living in rural areas had poorer results on 14 of 39 clinical quality measures, similar results on 23 measures, and better results on just two measures.2 The largest differences were for three clinical care measures with substantial deficits among rural residents, namely (a) avoiding potentially harmful drug-disease interactions in elderly patients with dementia (an 11-percentage-point deficit), (b) initiation of alcohol and other drug treatment (a 10-percentage-point deficit), and (c) controlling high blood pressure among patients with diabetes (a 10-percentage-point deficit).

Rural-Urban Disparities in Health Care in Medicare by Racial and Ethnic Group

The overall pattern of rural and urban residents reporting similar experiences with care generally held across racial and ethnic groups (American Indian or Alaska Native [AI/AN], Asian or Pacific Islander [API], Black, Hispanic, and White) and coverage types (Medicare FFS and MA). One notable exception involved


1 Beneficiaries were classified as living in a rural or urban area based on the zip code of their mailing address and the corresponding Census Bureau core-based statistical area (CBSA). CBSAs consist of the county or counties associated with at least one core urban area plus adjacent counties having a high degree of social and economic integration with the core. Metropolitan statistical areas contain a core urban area with a population of 50,000 or more. Micropolitan statistical areas contain a core urban area with a population of at least 10,000 but less than 50,000. For this report, any beneficiary residing within a metropolitan statistical area was classified as an urban resident; any beneficiary living in a micropolitan statistical area or outside of a CBSA was classified as a rural resident.

2 Here, “similar” is used to characterize differences that are not statistically significant, fall below a magnitude threshold, or both, as described in the appendix. “Worse” and “better” are used to characterize differences that are statistically significant and exceed a magnitude threshold.

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