GW researchers launched an online tracker last month highlighting disparities in Medicaid access across rural and urban populations that experts say lead to fewer primary care visits and preventable hospitalizations in rural areas.
Researchers at GW’s Mullan Institute for Health Workforce Equity developed the tracker, which allows users to view how many health care providers accepted Medicaid at a county level from 2016 to 2021. Anushree Vichare — co-creator of the tracker and an associate professor at the Milken Institute School of Public Health — said the tracker’s data revealed that rural counties had fewer Medicaid-participating primary care providers, despite studies showing more people in rural areas use Medicaid, a discrepancy in care that experts said could lead to increased hospitalizations.
Vichare said the tracker revealed that rural areas face a lack of providers accepting Medicaid, an overreliance on nurse practitioners and fewer medical specialists, which experts in health care policy said could lead to more preventable hospitalizations and misdiagnoses.
“It’s like a double sort of edge sword because even though they have Medicaid coverage, right, the coverage may not always guarantee access to primary care providers due to a lot of these structural barriers,” Vichare said.
Medicaid is a federal and state medical insurance program that helps cover health care costs for certain low-income people, the elderly and people with disabilities, with rules around eligibility depending on the state. The Kaiser Family Foundation reported in June that 24 percent of people living in rural areas use Medicaid, compared to 21 percent in urban areas.
Rural counties had significantly fewer Medicaid-participating providers — or providers that accepted Medicaid as compensation for their services — per 100,000 people enrolled, compared to urban counties from 2016 to 2021, according to the tracker.
The researchers found that many states have counties with no Medicaid-participating providers, including in Georgia, where eight out of the state’s 159 counties have no providers that helped 11 or more Medicaid patients in 2021.
The highlighted disparities come as Medicaid faces national funding cuts. The One Big Beautiful Bill Act, which President Donald Trump signed into law in July, constitutes the largest cut in Medicaid history, with a gross reduction of $990 billion over the next 10 years in federal Medicaid spending, according to the non-partisan Congressional Budget Office. The Kaiser Family Foundation estimates these cuts will reduce Medicaid spending in rural areas by $137 billion over 10 years.
Patricia Pittman, a co-creator of the tracker and the director of the Mullan Institute, said researchers and policymakers can use the data to identify local communities most in need of support and apply targeted measures to help.
“It can be used to identify areas of highest need so that you can invest money and target your policies in areas of highest need,” Pittman said. “And it can be used to look at changes over time to see whether a policy has been effective or ineffective in a particular regard.”
The researchers used data on Medicaid claims from the Transformed Medicaid Statistical Information System between 2016 and 2021. T-MSIS, a resource created by the Centers for Medicare and Medicaid Services, collects Medicaid enrollment data, patient costs and provider participation for research and policy use. The researchers used the data to track the health care workforce that cares for Medicaid beneficiaries in rural areas.
Pittman said the Medicaid claims data the researchers used shows that the “poorest” people in the country face the greatest disparities in health care access, including reduced access to providers.
She said Medicaid’s lower reimbursement rates — or payments insurance providers use to pay medical practitioners back for their services — act as a deterrent for rural health care providers accepting Medicaid. In 2020, hospitals only received 88 cents on the dollar in Medicaid reimbursements, according to the American Hospital Association.
“We wanted to be able to shine a light on those types of providers and changes over time where we were not seeing availability of providers, with the hope that policies could be designed to address that problem,” Pittman said.
Janice Probst, a professor emeritus from the University of South Carolina’s Arnold School of Public Health, said the new tracker is useful because, unlike previous studies that only count the number of health care providers in rural areas, the tracker incorporates the added layer of Medicaid availability. Other studies may make it seem like rural communities have adequate access to care, without addressing that people in these areas cannot afford the care because the providers don’t accept Medicaid, she said.
“This new study is important because the fact that a provider is there does not mean they will take Medicaid,” Probst said.
Probst also said rural areas have experienced higher rates of preventable hospitalizations because many of their residents cannot afford primary care. For example, she said a patient with diabetes may not be able to get regular physician checkups to avoid hospitalization by treating issues before symptoms get more severe.
Rural residents are less likely to receive preventive health procedures than urban residents, with rural patients being 3 percent more likely to make emergency room visits than urban patients in any given year, according to the Maine Rural Health Research Center.
“Since the people are poor, they don’t got these nice things where you can visit with a registered dietitian or other diabetes educator and learn how to control your disease,” Probst said.
The tracker also demonstrated a lack of medical specialists in rural areas, with many counties lacking OB-GYNs. For example, West Virginia has 14 adjacent counties with no maternal care providers.
Probst said 40 percent of all births nationally are covered by Medicaid, including 47 percent of births in rural counties. Despite a lack of OB-GYN specialists in these counties, Probst said OB-GYNs are less likely to refuse Medicaid patients because so much of their revenue comes from patients on the program.
“OB-Gs will be cutting off a lot of their business,” Probst said.
The tracker also found the provider-to-population ratio for nurse practitioners in rural areas increased from 165 per 100,000 people in 2016 to 236 in 2021.
Nurse practitioners undergo less training than doctors, with some getting their degree 18 months after becoming a registered nurse, compared to doctors who are required to graduate from a four-year medical school and complete a three-to-seven-year residency training program, the length of which depends on the specific field. This less intensive training can lead to problems like misdiagnosis, according to the American Medical Association.
Alana Knudson, the director of the NORC Walsh Center for Rural Health Analysis, said laws requiring that rural health clinics be staffed by nurse practitioners, physician assistants and certified nurse midwives 50 percent of the time are the root cause of the increased ratio of nurse practitioners.
Knudson said the data provided by the tracker is valuable because there is a lack of information regarding primary care providers in rural areas. But she added that the Mullan Institute’s finding that the ratio increased from 2016 to 2021 is not an economic disparity but rather a requirement by law.
“So when we are looking at disparities, we need to be very clear about what we are calling a disparity because it can’t be solely about primary care physicians,” Knudson said.
