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Rural–Urban Health Disparities among US Adults Ages 50 and Older

20 million Americans ages 50 and older live in rural areas, and rural areas are experiencing faster growth of their older adult population than urban areas.  While there can be many benefits to living in rural areas, rural residents face longstanding health care access challenges that contribute to well-documented health disparities compared to urban areas.

Older Adults in Rural Areas Need Better Health Care Access

Existing research shows that rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than are those living in urban areas. These disparities are closely tied to the social determinants of health—that is, the conditions that impact health in the environments where people are born, live, learn, work, play, worship, and age. Contributors to rural health disparities include economic factors such as higher rates of poverty and limited job opportunities, health care access factors such as lower rates of health insurance and limited access to health care providers, and environmental factors such as geographic isolation and lack of transportation. 

Despite growing populations of older adults in rural areas, few studies have analyzed rural–urban or racial and ethnic disparities within the older population. This report analyzes several variables across three areas – health care access, health-related behaviors, and health conditions – among adults ages 50-64 and 65+ living in rural versus urban areas. The report also reports data among older rural and urban residents by race and ethnicity.

This study utilizes data collected from the Center for Disease Control and Prevention’s 2019 Behavioral Risk Factor Surveillance System (BRFSS) and focuses on the following variables: health insurance status, individuals who went without medical care due to cost, certain health conditions (heart disease, stroke, cancer, diabetes, obesity), health-related behaviors (smoking, drinking, leisure-time physical activity), urban versus rural place of residence, and race and ethnicity. Urban versus rural place of residence was determined using the 2013 National Center for Health Statistics six-level urban/rural classification scheme for counties based on the designation of metropolitan and micropolitan statistical areas.

The limitations and challenges of working with rural health data are discussed in the report.

Health Care Access

The report finds that adults ages 50 to 64 living in rural areas were more likely to be uninsured compared with those living in urban areas (12 percent v. 11 percent), while there was no difference in insurance status among those ages 65 and older, presumably owing to Medicare. Still, rural adults ages 65+ were more likely to forgo medical care due to cost compared with those living in urban areas (6 percent v. 5 percent). Among adults ages 50 to 64, 15 percent living in rural areas had to forgo health care due to cost versus 13 percent of those living in urban areas. 

In both rural and urban areas, Black and Hispanic adults ages 50 and older were much more likely than their White counterparts to be uninsured and to have skipped medical care due to cost; the gap, however, is wider in rural areas. Notably, the uninsured rate among Hispanic older adults living in both rural and urban areas was significantly higher than that among their Black and White counterparts. 

Health Conditions

Both White and Black older adults living in rural areas were more likely compared with those living in urban areas to report having been told by a health professional that they have heart disease, stroke, diabetes, cancer, or obesity, with obesity showing the widest difference.  Hispanic adults ages 50+ living in rural areas had higher prevalence of stroke, cancer, and obesity and lower prevalence of heart disease and diabetes compared with older Hispanics living in urban areas. A Black–White gap in prevalence of stroke and diabetes was greater among those in rural areas than in urban areas, suggesting that additional factors, such as more limited access to health care or coverage in rural areas, may exacerbate racial disparities in certain health conditions. 

Health Behaviors 

Older adults living in rural areas were more likely to be current smokers and more likely to not engage in leisure-time physical activity compared with those living in urban areas, and this cut across racial and ethnic groups. Black adults ages 50 and older living in rural areas reported the highest prevalence of smoking and physical inactivity. 

Detailed charts and an appendix are included in the report.

Suggested citation:

Carter, Beth, and Olivia Dean. Rural-Urban Health Disparities among US Adults Ages 50 and Older. Washington, DC: AARP Public Policy Institute, October 2021.