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Regional Matters

September 30, 2020

Rural-Urban Health Disparities in the Fifth District Before COVID-19

Introduction

The COVID-19 pandemic has challenged the health care infrastructure and highlighted rural-urban disparities in health and health care access across the country. It has also reinforced the critical role that a healthy workforce and robust health care infrastructure play in a community’s economic growth and stability. Prior to the pandemic, many rural communities had been disproportionately impacted by health care workforce shortages along with social and economic barriers to health relative to urban communities. Rural hospitals, which often serve as important economic drivers and anchor institutions, have been closing or reducing services in areas that already faced barriers to health and health care access. Recognizing health-related differences that predated the pandemic could help rural and urban communities develop strategies to leverage community assets to support community and economic health. In anticipation of the Richmond Fed’s Rural America Week, culminating in the Investing in Rural America Conference on October 8, this Regional Matters post examines the 2020 RWJF’s County Health Rankings data to understand how health drivers in Fifth District rural and urban counties compared prior to the pandemic and how the impacts of COVID-19 may shift the landscape.

RWJF County Health Rankings & Roadmaps

The County Health Rankings & Roadmaps program is a partnership between the RWJF and the University of Wisconsin Population Health Institute. Using a population health model that incorporates the wide range of factors that influence health outcomes, the team produces annual health rankings of counties within each state along with resources for stakeholders to address the health-related needs in their communities.

Each county receives two primary rankings within their respective states, which are calculated from variables that have been standardized and weighted into subrankings. (See table below.) Health Outcomes represent a community’s current health through length and quality of life metrics. Health Factors represent the determinants of health and is designed to highlight opportunities for communities to address in order to improve future health outcomes.

County Health RankingsWeight - Subranking
Health Outcomes
  • 50% - Length of life
  • 50% - Quality of life
 Health Factors
  • 40% - Social and economic factors
  • 30% - Health behaviors
  • 20% - Clinical care
  • 10% - Physical environment

Source: 2020 RWJF County Health Rankings Model

The 2020 County Health Rankings use data largely from 2016-2019, with some exceptions. The County Health Rankings team publishes the county-level data used in the ranking calculations along with supplementary measures of health factors and outcomes that were not included in the rankings calculations but provide additional information on community characteristics that drive health.

How Do Rural and Urban Counties Rank in the Fifth District?

We analyzed the 2020 County Health Rankings for the counties and county-equivalents in Maryland, North Carolina, South Carolina, Virginia, and West Virginia. Using the U.S. Department of Agriculture’s 2013 Rural-Urban Continuum Codes with the County Health Rankings, we categorize each county as urban (Metro codes 1-2) or rural (Metro/Non-Metro codes 3-9). Using this categorization, 215 counties are classified as rural, and 143 are urban. In addition to numerical rankings, the County Health Rankings data include each county’s quartile within its state for each of the rankings, subrankings, and underlying measures. Counties in the top quartile rank highest, or “healthiest,” within their state.

Health Outcomes Rankings and Subrankings

For the Fifth District overall, urban counties tend to rank higher than their rural counterparts on the health outcomes. The distribution of counties by state quartile shows that urban counties disproportionately comprise the top quartile of health outcome rankings across the district. Nearly 90 percent of urban counties in the district rank within the top three quartiles within their respective states. (See chart below.)

The aggregate Fifth District county distribution is not uniform across the district. For example, in Maryland, 24 percent of rural counties ranked in the top quartile, while only 8 percent of South Carolina’s rural counties ranked in the state’s top quartile.

Urban counties dominated the high rankings overall in the district for both length and quality of life but accounted for a higher percentage of the top quartile for quality of life (45 percent) than length of life (36 percent). Like the overall health outcomes rankings, the quality of life subrankings distribution, shown in the chart below, varied significantly between states. All states in the district had a higher proportion of urban than rural counties in the top quartile. West Virginia’s six urban counties were divided evenly between the top and bottom quartiles, while the state’s rural counties were more evenly distributed across the quartiles.

Source: 2020 County Health Rankings; author's calculations

Note: The red line indicates the percentage of rural and urban counties we would expect in each quartile if urban and rural counties were evenly distributed across the rankings. A bar that is higher than the red line indicates the county type it represents (urban or rural) is overrepresented in that quartile of the rankings distribution. The quality of life subranking includes measures of low birth weights and health survey data. A detailed description of the variables included in the subranking are available in the 2020 County Health Rankings Data & Documentation.

Relative rurality may drive some of the variation in the highest and lowest rated counties. Two rural counties, Beaufort in South Carolina, and Monongalia in West Virginia, hold the top rankings among all counties in their respective states for health outcomes. While rural by our simplified classification, these counties, and several others in the top quartile, include a mix of urban and rural areas and likely benefit from the positive health factors in both areas.

While the rankings calculations include years of potential life lost as the length of life subranking, the County Health Rankings data includes county-level measures of life expectancy at birth as an alternative way to compare length of life within states. Urban counties had higher median life expectancy than rural counties overall, but there is no significant difference in the median life expectancy for urban and rural counties in the top quartile of the rankings. There is significant variation between states and within rural and urban counties within each state.

Life Expectancy at Birth (Years)

Highest County

State County Median

Lowest County

Urban

Rural

Urban

Rural

Urban

Rural

Maryland

84.4

81.4

78.7

78.7

72.8

75.9

North Carolina

82.1

82

77.4

76.6

75.2

73.2

South Carolina

79.8

82.6

77

74.2

73.6

67.5

Virginia

92.5

83

78.5

76.4

67.9

67.5

West Virginia

77.6

79.1

74.7

75.9

71.4

68.6

Source: 2020 County Health Rankings; author's calculations

Health Factor Rankings and Subrankings

The distribution of rural and urban counties for the overall health factors rankings follows closely with the health outcome rankings, but urban counties represented a higher share (41 percent) of their states’ top quartile. Only 14 percent of rural counties in the district ranked in their state’s top health factors quartile, though the distribution varied by state. Maryland had the most even distribution across the quartiles, and South Carolina’s distribution favored urban counties more than the other states. The urban-rural distribution varied across the underlying health factor subrankings for all counties combined across Fifth District states. (See chart below.)

Source: 2020 County Health Rankings; author's calculations

Note: The red line indicates the percentage of rural and urban counties we would expect in each quartile if urban and rural counties were evenly distributed across the rankings. A bar that is higher than the red line indicates the county type it represents (urban or rural) is overrepresented in that quartile of the rankings distribution. The social and economic subranking includes measures of employment, education, income, social and family supports, and crime. The health behaviors subranking includes measures of substance use, diet and exercise, and sexual activity. The clinical care subranking measures access to and quality of health care, including health insurance coverage. The physical environment subranking measures housing, transit, and air and water quality. A detailed description of the variables included in each subranking are available in the 2020 County Health Rankings Data & Documentation.

Fifth District rural counties, on average, performed best on the physical environment subranking, which measures a county’s housing quality and affordability, transit, and air and water quality. Urban counties accounted for the majority of the top two rankings quartiles for the health behaviors subranking, which includes measures of diet and nutrition and substance use among residents, and the clinical care subranking, which measures a county’s access to and quality of health care. The largest overall urban-rural gap in the underlying health factors data is in the social and economic factors subranking, which accounts for 40 percent of the overall health factors score and includes key drivers like educational attainment, unemployment, income inequality, and violent crime. The chart below shows the distribution of urban and rural counties detailed by state and illustrates the variation in relative rural-urban rankings across Fifth District states.

Source: 2020 County Health Rankings; author's calculations

Note: The red line indicates the percentage of rural and urban counties we would expect in each quartile if urban and rural counties were evenly distributed across the rankings. A bar that is higher than the red line indicates the county type it represents (urban or rural) is overrepresented in that quartile of the rankings distribution. A detailed description of the variables included in each subranking are available in the 2020 County Health Rankings Data & Documentation.

These rankings include data collected prior to the emergence of COVID-19 in the United States, and some of the pandemic’s short- and long-term impacts on health and economic stability are already taking shape. The direct health consequences of the virus are still critical, but there will likely be significant shifts in variables that drive the health factor rankings shown in the charts above that vary across counties in the Fifth District. Underlying variables in the social and economic conditions and clinical care quality and access subrankings, where rural counties were outperformed by urban counties, have been impacted already. Job losses, furloughs, and labor income changes have put pressure on household finances and raised concerns about housing and food insecurity. Educational disruptions could have a lasting impact and worsen existing disparities in access and attainment. The COVID-19 pandemic will undoubtedly change the health care landscape and could put increasing pressure on resource-constrained rural hospitals. Foregone preventative care due to health facility closures and service reductions could significantly impact communities where health care access is already limited. Expanding rural broadband is a key step to widespread implementation and funding of telemedicine, which is frequently cited as a potential solution to health care in some rural areas and may gain traction as the pandemic persists.

Conclusion

The COVID-19 pandemic has impacted community health and economic outcomes in rural and urban communities across the district. The RWJF County Health Rankings data are a valuable resource in understanding health disparities and opportunities for improvement within states. In the Fifth District, rural counties tend to rank lower across health outcomes and factors, but some rural communities outperform urban counties on key measures, and there is significant variation in the rural-urban gap between states. The rankings can guide researchers, policymakers, and stakeholders toward key issue areas, but targeted action requires a closer look at the individual health drivers and their differential effect on communities. While some of the underlying data sources include racial and ethnic subgroupings, county-level data provide little direct insight into socioeconomic, racial, and spatial disparities within counties. Comparing rankings across broad geographic designations mask significant variation along the urban-rural continuum, but additional community level data and insight can help contextualize community strengths and opportunities. A barrier to health that is quantitatively similar in two counties may be experienced differently in a rural and an urban county, or in two rural communities with different geographies and economic drivers. Solutions to a common problem may require different programs, policy levers, and resource channels in diverse communities. As data become available on the health and economic impacts of COVID-19, understanding pre-pandemic health-related strengths and vulnerabilities could provide insight into recovery and build resiliency for rural and urban communities in the Fifth District.


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Views expressed are those of the authors and do not necessarily reflect those of the Federal Reserve Bank of Richmond or the Federal Reserve System.

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