March 2012

Document Type


Degree Name



Dept. of Public Health and Preventive Medicine


Oregon Health & Science University


Background: Rural citizens face many barriers to accessing and utilizing both health care services and health insurance. Medicaid covers a large portion of the Oregon population, represents a high-risk group that is distinct from the general population and plays a particularly crucial role in rural health systems. For individuals without health insurance, accessing health care services can be difficult and can lead to accruing substantial medical debt. While comparisons among the general population indicate that rural citizens are at a higher risk of less access and utilization than their urban counterparts, few studies have examined these differences longitudinally among a Medicaid population. There is some evidence to suggest that urban and rural populations to have similar risk for less access and utilization when compared within a Medicaid population. The current study is framed in a time of significant policy changes for Oregon’s State Medicaid program, the Oregon Health Plan (OHP), when the State sought to increase enrollment by creating the OHP2 by shifting costs to a group of enrollees through premiums, copays and decreased benefit packages. In the ensuring months enrollment plummeted leaving many Oregonians without health insurance. Objective: We sought to examine differences between urban and rural populations with reference to access, utilization, medical debt and time spent uninsured among beneficiaries of the OHP2 during a time of significant State Medicaid policy changes. Methods: We utilized the Andersen Behavioral Model of Health Services Use as a conceptual model to frame our investigation. Our analyses utilized results from the Oregon Health Care Survey, a three-wave longitudinal panel study developed and implemented between 2003 and 2006 by the Providence Center for Outcomes Research and Education (CORE) and Portland State University. Our analyses included the 1535 adults who completed all three study surveys. We utilized univariate and multivariate logistic regression analyses to investigate the impact of living in a rural area on reported unmet medical need, unmet prescription need due to cost, unmet urgent care need, utilization of primary care services, utilization of emergency care services, medical debt and time spent uninsured while controlling for a common set of potential confounding variables. Results: The results of the univariate analyses indicated that rural respondents were older, more educated and more likely to be Caucasian than urban respondents. Spending time without insurance was associated with increased risk for each of the outcomes except emergency department utilization. Further, the risk for these outcomes increased with increasing time spent uninsured. The multivariate models comparing rural versus urban revealed that the risk for unmet medical need, unmet prescription need due to cost, unmet urgent care need, going without primary care and emergency services and having greater medical debt were similar. Results also indicate that rural and urban respondents are equally likely to spend any amount of time uninsured. Conclusions: Our findings support prior research, indicating that the longer individuals spend without health insurance the greater is their risk for less access and utilization of health care services, and greater medical debt. In addition, our results support the conclusions of prior research examining rural/urban differences within the Medicaid population, that rural and urban citizens experience similar levels of risk for less access and less utilization of health care services within this distinct population. State officials should incorporate an understanding of urban/rural differences in both population compositions and health system structures into Medicaid policies in order to ensure that all Medicaid enrollees receive the same opportunity for good health, regardless of where they live.




School of Medicine



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.